Provider Demographics
NPI:1851304133
Name:RIDDICK, DAVID ERWIN (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ERWIN
Last Name:RIDDICK
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72616-0365
Mailing Address - Country:US
Mailing Address - Phone:870-423-3832
Mailing Address - Fax:870-423-2995
Practice Address - Street 1:801 W TRIMBLE AVE
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-5101
Practice Address - Country:US
Practice Address - Phone:870-423-3832
Practice Address - Fax:870-423-3832
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR32641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR974643OtherUNITED CONCORDIA BC/BS
AR5T911OtherBLUE CROSS BLUE SHIELD