Provider Demographics
NPI:1225257082
Name:RIDGWAY JR., DONIVAN LEONARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONIVAN
Middle Name:LEONARD
Last Name:RIDGWAY JR.
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 1:6329 ORAM ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-3931
Mailing Address - Country:US
Mailing Address - Phone:214-823-1638
Mailing Address - Fax:214-823-1169
Practice Address - Street 1:6329 ORAM ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-3931
Practice Address - Country:US
Practice Address - Phone:214-823-1638
Practice Address - Fax:214-823-1169
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10075122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist