Provider Demographics
NPI:1336559475
Name:WEDLAKE, RILEY (DMD)
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:WEDLAKE
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 1:2131 LAWRENCE ST
Mailing Address - Street 2:APT 403
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-2349
Mailing Address - Country:US
Mailing Address - Phone:509-994-9119
Mailing Address - Fax:
Practice Address - Street 1:3960 RIVER POINT PKWY # A
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:CO
Practice Address - Zip Code:80110-3315
Practice Address - Country:US
Practice Address - Phone:303-781-2340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN002026201223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program