Provider Demographics
NPI:1053093351
Name:RIDER FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:RIDER FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:317-201-3576
Mailing Address - Street 1:15884 VIKING LAIR RD
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-5526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2481
Practice Address - Country:US
Practice Address - Phone:317-259-1501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental