Individual
DR. RICHARD C VANDIVER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1625 DAVID RAINES RD, SHREVEPORT, LA 71107-5899
(318) 841-6048
(318) 841-6044
Mailing address
2125 E BERT KOUNS INDUSTRIAL LOOP, UNIT #3, SHREVEPORT, LA 71105-5314
(318) 349-1909
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
4538
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
20409
CDS #
LA
01
—
4538
STATE BOARD LICENSE
LA
Enumeration date
02/20/2007
Last updated
03/07/2023
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