Provider Demographics
NPI:1851361612
Name:RIDLEY, JAMES DEAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DEAN
Last Name:RIDLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 BOULEVARD STREET
Mailing Address - Street 2:JACKSONVILLE VA OUTPATIENT CLINIC
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-4394
Mailing Address - Country:US
Mailing Address - Phone:904-232-2751
Mailing Address - Fax:
Practice Address - Street 1:1833 BOULEVARD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-4394
Practice Address - Country:US
Practice Address - Phone:904-232-2751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31971122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist