Provider Demographics
NPI:1609476647
Name:RIDEAU, CORIE ZENOBIA
Entity Type:Individual
Prefix:
First Name:CORIE
Middle Name:ZENOBIA
Last Name:RIDEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26511 THOROUGHBRED LN
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-2965
Mailing Address - Country:US
Mailing Address - Phone:951-210-5144
Mailing Address - Fax:
Practice Address - Street 1:26511 THOROUGHBRED LN
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-2965
Practice Address - Country:US
Practice Address - Phone:951-210-5144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA93999126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB5891651Medicaid