Provider Demographics
NPI:1003354929
Name:RILEY, JAMILA SHANI MCKINNIS (DDS)
Entity Type:Individual
Prefix:
First Name:JAMILA
Middle Name:SHANI MCKINNIS
Last Name:RILEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JAMILA
Other - Middle Name:SHANI
Other - Last Name:MCKINNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3805 AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-1619
Mailing Address - Country:US
Mailing Address - Phone:251-343-9998
Mailing Address - Fax:337-828-4717
Practice Address - Street 1:3805 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1619
Practice Address - Country:US
Practice Address - Phone:251-343-9998
Practice Address - Fax:337-828-4717
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-11
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA69071223G0001X
FLDN231871223G0001X
390200000X
AL68301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2485130Medicaid