Provider Demographics
NPI:1437810637
Name:RIYAN DENTAL LLC
Entity Type:Organization
Organization Name:RIYAN DENTAL LLC
Other - Org Name:WEST EDGEWOOD DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJENDAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-617-7417
Mailing Address - Street 1:14031 WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8317
Mailing Address - Country:US
Mailing Address - Phone:205-617-7417
Mailing Address - Fax:
Practice Address - Street 1:3306 EMERALD LN
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6880
Practice Address - Country:US
Practice Address - Phone:573-634-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-10
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty