Provider Demographics
NPI:1932770609
Name:RIDDLE MODERN DENTISTRY & IMPLANTS
Entity Type:Organization
Organization Name:RIDDLE MODERN DENTISTRY & IMPLANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-651-8298
Mailing Address - Street 1:10412 STONELEIGE ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-0740
Mailing Address - Country:US
Mailing Address - Phone:479-651-8298
Mailing Address - Fax:
Practice Address - Street 1:2600 MARKET TRCE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-8681
Practice Address - Country:US
Practice Address - Phone:479-651-8298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental