Provider Demographics
NPI:1013964147
Name:D. CALVIN RILEY JR. DMD PA
Entity Type:Organization
Organization Name:D. CALVIN RILEY JR. DMD PA
Other - Org Name:CRESCENT BEACH DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:CALVIN
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:843-272-1121
Mailing Address - Street 1:602 17TH AVE SO
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582
Mailing Address - Country:US
Mailing Address - Phone:843-272-1121
Mailing Address - Fax:843-272-9976
Practice Address - Street 1:602 17TH AVE SO
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582
Practice Address - Country:US
Practice Address - Phone:843-272-1121
Practice Address - Fax:843-272-9976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ2681Medicaid
SCZA9478Medicaid