Provider Demographics
NPI:1184275786
Name:RILEY, KRISTEN DANNIELLE (RDH)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:DANNIELLE
Last Name:RILEY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:DANNIELLE
Other - Last Name:BLACKWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1632 CAMPHOR WAY
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4422
Mailing Address - Country:US
Mailing Address - Phone:209-992-0398
Mailing Address - Fax:
Practice Address - Street 1:83 W MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5730
Practice Address - Country:US
Practice Address - Phone:209-636-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23044124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist