Provider Demographics
NPI:1194494831
Name:RIDER, KYLEE (DMD)
Entity type:Individual
Prefix:DR
First Name:KYLEE
Middle Name:
Last Name:RIDER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8486 CAMPBELLTON ST UNIT 2211
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30133-0375
Mailing Address - Country:US
Mailing Address - Phone:470-626-5735
Mailing Address - Fax:
Practice Address - Street 1:8590 BOWDEN ST
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-4525
Practice Address - Country:US
Practice Address - Phone:770-949-1680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1224581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice