Provider Demographics
NPI:1265630636
Name:RIDENOUR, MARK J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:RIDENOUR
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 1:1875 W POINTE DR
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-4174
Mailing Address - Country:US
Mailing Address - Phone:920-231-4600
Mailing Address - Fax:
Practice Address - Street 1:1875 W POINTE DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-4174
Practice Address - Country:US
Practice Address - Phone:920-231-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6044-151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery