Provider Demographics
NPI:1255867982
Name:RILEY, TANESHA
Entity Type:Individual
Prefix:
First Name:TANESHA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14025 ANDERSON ST APT C
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-2770
Mailing Address - Country:US
Mailing Address - Phone:562-240-9141
Mailing Address - Fax:
Practice Address - Street 1:14025 ANDERSON ST APT C
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-2770
Practice Address - Country:US
Practice Address - Phone:562-240-9141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57557126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant