Provider Demographics
NPI:1457449092
Name:RIESER, ANDREW RAYMOND (DMD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:RAYMOND
Last Name:RIESER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4756 AUBURN TRACE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2851
Mailing Address - Country:US
Mailing Address - Phone:314-200-8216
Mailing Address - Fax:
Practice Address - Street 1:1351 JEFFERSON ST
Practice Address - Street 2:SUITE 308
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-6449
Practice Address - Country:US
Practice Address - Phone:636-239-7654
Practice Address - Fax:636-239-5598
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030151901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice