Provider Demographics
NPI:1669217683
Name:RIDENOUR, TAYLOR (DDS)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:RIDENOUR
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 1:19428 MIZE LN
Mailing Address - Street 2:
Mailing Address - City:SPIRO
Mailing Address - State:OK
Mailing Address - Zip Code:74959-4342
Mailing Address - Country:US
Mailing Address - Phone:479-462-5233
Mailing Address - Fax:
Practice Address - Street 1:318 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SPIRO
Practice Address - State:OK
Practice Address - Zip Code:74959-2422
Practice Address - Country:US
Practice Address - Phone:918-962-2466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK78781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice