Provider Demographics
NPI:1790122273
Name:RIDDER, JACLYN KRISTINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:KRISTINE
Last Name:RIDDER
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 1:15540 BRACKENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-6704
Mailing Address - Country:US
Mailing Address - Phone:317-418-1342
Mailing Address - Fax:
Practice Address - Street 1:15887 CUMBERLAND RD STE 104
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060
Practice Address - Country:US
Practice Address - Phone:317-770-4783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011954A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice