Provider Demographics
NPI:1407324551
Name:JACLYN RIDDER DDS, LLC
Entity Type:Organization
Organization Name:JACLYN RIDDER DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:KRISTINE
Authorized Official - Last Name:RIDDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-418-1342
Mailing Address - Street 1:15540 BRACKENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-6704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15887 CUMBERLAND RD STE 104
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-4332
Practice Address - Country:US
Practice Address - Phone:317-770-4783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental