Provider Demographics
NPI:1619391869
Name:RIDENOUR, STEPHEN J (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:RIDENOUR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1224
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1224
Mailing Address - Country:US
Mailing Address - Phone:715-834-8414
Mailing Address - Fax:715-834-3557
Practice Address - Street 1:788 OAKLEAF WAY
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720
Practice Address - Country:US
Practice Address - Phone:715-834-8414
Practice Address - Fax:715-834-3557
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10017411223S0112X
IA30409390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program