Provider Demographics
NPI:1942361365
Name:RIDDLE, GARY LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LYNN
Last Name:RIDDLE
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 1:1420 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63780-1936
Mailing Address - Country:US
Mailing Address - Phone:573-264-2020
Mailing Address - Fax:573-264-2678
Practice Address - Street 1:1420 MAIN ST
Practice Address - Street 2:
Practice Address - City:SCOTT CITY
Practice Address - State:MO
Practice Address - Zip Code:63780-1936
Practice Address - Country:US
Practice Address - Phone:573-264-2020
Practice Address - Fax:573-264-2678
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO137731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO401916408Medicaid