Provider Demographics
NPI:1811390230
Name:RILEY, RAYNARD OTIS (DDS)
Entity Type:Individual
Prefix:MR
First Name:RAYNARD
Middle Name:OTIS
Last Name:RILEY
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 1:475 SPRINGFIELD AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901
Mailing Address - Country:US
Mailing Address - Phone:908-273-5656
Mailing Address - Fax:908-273-5661
Practice Address - Street 1:475 SPRINGFIELD AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901
Practice Address - Country:US
Practice Address - Phone:908-273-5656
Practice Address - Fax:908-273-5661
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D102143400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist