Provider Demographics
NPI:1750010542
Name:RIEDEL, BROCK (DMD)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:
Last Name:RIEDEL
Suffix:
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 1:55 WEST 5TH
Mailing Address - Street 2:APT 605
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127
Mailing Address - Country:US
Mailing Address - Phone:785-320-1841
Mailing Address - Fax:
Practice Address - Street 1:862 LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-4849
Practice Address - Country:US
Practice Address - Phone:781-684-9714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859503122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program