Provider Demographics
NPI:1285640383
Name:RILEY, PAUL (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:RILEY
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 1:108 S MAPLE ST STE C
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2305
Mailing Address - Country:US
Mailing Address - Phone:769-567-2555
Mailing Address - Fax:
Practice Address - Street 1:108 S MAPLE ST STE C
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2305
Practice Address - Country:US
Practice Address - Phone:769-567-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2359-871223G0001X
MSOP-6042-231223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X2210XDental ProvidersDentistOrofacial Pain
No1223G0001XDental ProvidersDentistGeneral Practice