Provider Demographics
NPI:1679684740
Name:RIDDLE DENTAL CARE ASSOCIATES
Entity type:Organization
Organization Name:RIDDLE DENTAL CARE ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER SEC TREAS
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-874-3126
Mailing Address - Street 1:PO BOX 107
Mailing Address - Street 2:150 S MAIN
Mailing Address - City:RIDDLE
Mailing Address - State:OR
Mailing Address - Zip Code:97469
Mailing Address - Country:US
Mailing Address - Phone:541-863-5524
Mailing Address - Fax:541-874-3259
Practice Address - Street 1:150 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RIDDLE
Practice Address - State:OR
Practice Address - Zip Code:97469
Practice Address - Country:US
Practice Address - Phone:541-874-3126
Practice Address - Fax:541-874-3259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR67741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR074612Medicaid
OR6774OtherDENTAL