Provider Demographics
NPI:1790239457
Name:JACOB J. RIDL DDS PLLC
Entity Type:Organization
Organization Name:JACOB J. RIDL DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:J
Authorized Official - Last Name:RIDL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PLLC
Authorized Official - Phone:509-235-6241
Mailing Address - Street 1:1717 1ST ST
Mailing Address - Street 2:P.O. BOX A
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:P.O. BOX A
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE600934861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty