Provider Demographics
NPI:1679062020
Name:RIVERSIDE PRACTICE, LLC
Entity Type:Organization
Organization Name:RIVERSIDE PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-802-9534
Mailing Address - Street 1:12613 SCOFIELD FARMS DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-4542
Mailing Address - Country:US
Mailing Address - Phone:225-802-9534
Mailing Address - Fax:
Practice Address - Street 1:2410 E RIVERSIDE DR STE H12
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-3054
Practice Address - Country:US
Practice Address - Phone:512-442-1224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195206120Medicaid