Provider Demographics
NPI:1174697957
Name:RICHARDSON OVERSTREET, SUSAN R (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:R
Last Name:RICHARDSON OVERSTREET
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:R
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:39 W WILLIAMSBURG RD
Mailing Address - Street 2:
Mailing Address - City:SANDSTON
Mailing Address - State:VA
Mailing Address - Zip Code:23150
Mailing Address - Country:US
Mailing Address - Phone:804-737-7402
Mailing Address - Fax:804-737-5442
Practice Address - Street 1:39 W WILLIAMSBURG RD
Practice Address - Street 2:
Practice Address - City:SANDSTON
Practice Address - State:VA
Practice Address - Zip Code:23150
Practice Address - Country:US
Practice Address - Phone:804-737-7402
Practice Address - Fax:804-737-5442
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAVA07682122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9182625Medicaid
VA983528OtherUNITED CONCORDIA
VA204679OtherANTHEM