Provider Demographics
NPI:1932113974
Name:RILEY, TIFFANY JEAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:JEAN
Last Name:RILEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:75 RILEY CIR
Mailing Address - Street 2:
Mailing Address - City:CALVERT CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42029-7803
Mailing Address - Country:US
Mailing Address - Phone:270-205-8197
Mailing Address - Fax:888-735-8036
Practice Address - Street 1:1927 IRVIN COBB DR
Practice Address - Street 2:SUITE 1
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-2105
Practice Address - Country:US
Practice Address - Phone:270-442-6617
Practice Address - Fax:270-442-0089
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY83781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100006580Medicaid