Provider Demographics
NPI:1114941614
Name:RILEY, MARILYN PATRICIA (DMD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:PATRICIA
Last Name:RILEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 N ANDREWS AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-5239
Mailing Address - Country:US
Mailing Address - Phone:954-561-6675
Mailing Address - Fax:954-630-2017
Practice Address - Street 1:3909 N ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33309-5239
Practice Address - Country:US
Practice Address - Phone:954-561-6675
Practice Address - Fax:954-630-2017
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17611122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076272502Medicaid