Provider Demographics
NPI:1558846725
Name:RIVERSIDE FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:RIVERSIDE FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARDY
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-728-5019
Mailing Address - Street 1:1445 WAMPANOAG TRL UNIT 209
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-1019
Mailing Address - Country:US
Mailing Address - Phone:401-433-2400
Mailing Address - Fax:401-433-2403
Practice Address - Street 1:1445 WAMPANOAG TRL UNIT 209
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-1019
Practice Address - Country:US
Practice Address - Phone:401-433-2400
Practice Address - Fax:401-433-2403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty