Provider Demographics
NPI:1629092879
Name:RILEY, ROSE A (DDS)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:A
Last Name:RILEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:CHAMBERLAIN
Mailing Address - State:SD
Mailing Address - Zip Code:57325-1640
Mailing Address - Country:US
Mailing Address - Phone:605-234-1099
Mailing Address - Fax:
Practice Address - Street 1:HWY 34 & 47
Practice Address - Street 2:
Practice Address - City:FORT THOMPSON
Practice Address - State:SD
Practice Address - Zip Code:57339-0200
Practice Address - Country:US
Practice Address - Phone:605-245-1518
Practice Address - Fax:605-245-2384
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM8931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5549010Medicaid