Provider Demographics
NPI:1780814582
Name:RIDL, JACOB JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:JOHN
Last Name:RIDL
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 1:1717 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-1903
Mailing Address - Country:US
Mailing Address - Phone:509-235-6241
Mailing Address - Fax:509-235-6218
Practice Address - Street 1:1717 1ST ST
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-1903
Practice Address - Country:US
Practice Address - Phone:509-235-6241
Practice Address - Fax:509-235-6218
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE600934861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice