Provider Demographics
NPI:1215035084
Name:RIDELLA, JOHN DAVID (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:RIDELLA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MENOHER BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905
Mailing Address - Country:US
Mailing Address - Phone:814-536-5646
Mailing Address - Fax:814-536-1774
Practice Address - Street 1:901 MENOHER BLVD
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905
Practice Address - Country:US
Practice Address - Phone:814-536-5646
Practice Address - Fax:814-536-1774
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA026351122300000X
PABR1727215122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist