Provider Demographics
NPI:1700013745
Name:RIDGEWAY, JAMES MICHAEL II (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MICHAEL
Last Name:RIDGEWAY
Suffix:II
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 N AVIATION BLVD
Mailing Address - Street 2:LOS ANGELES AFB/61MDS/SGD
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245
Mailing Address - Country:US
Mailing Address - Phone:310-653-6875
Mailing Address - Fax:
Practice Address - Street 1:483 N AVIATION BLVD
Practice Address - Street 2:LOS ANGELES AFB/61MDS/SGD
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245
Practice Address - Country:US
Practice Address - Phone:310-653-6875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC45971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice