Provider Demographics
NPI:1336496264
Name:RILEY, KELLY JO (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JO
Last Name:RILEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22500NW67TH AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-8534
Mailing Address - Country:US
Mailing Address - Phone:541-282-3787
Mailing Address - Fax:
Practice Address - Street 1:7725 NE HIGHWAY 99
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8834
Practice Address - Country:US
Practice Address - Phone:360-696-4487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60305453122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist