Provider Demographics
NPI:1083617484
Name:RILEY, VAN KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:KEITH
Last Name:RILEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 HAWSER LN
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5031
Mailing Address - Country:US
Mailing Address - Phone:239-262-5309
Mailing Address - Fax:239-262-1939
Practice Address - Street 1:1454 MADISON AVE W
Practice Address - Street 2:
Practice Address - City:IMMOKALEE
Practice Address - State:FL
Practice Address - Zip Code:34142-2200
Practice Address - Country:US
Practice Address - Phone:239-658-3198
Practice Address - Fax:239-658-3050
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD046871223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD04687OtherDENTAL LICENSE
FLD04687OtherDENTAL LICENSE
FLBC/BS 84899Medicare ID - Type UnspecifiedSTATE MEDICARE
FLD04687OtherDENTAL LICENSE