Provider Demographics
NPI:1215961529
Name:RIEDELL, KEITH BRUCE (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:BRUCE
Last Name:RIEDELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:K.
Other - Middle Name:BRUCE
Other - Last Name:RIEDELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:24 SUNRISE RD
Mailing Address - Street 2:
Mailing Address - City:BOXFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01921-2320
Mailing Address - Country:US
Mailing Address - Phone:978-887-5181
Mailing Address - Fax:
Practice Address - Street 1:10 DOANE ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:MA
Practice Address - Zip Code:01835-7405
Practice Address - Country:US
Practice Address - Phone:978-372-6800
Practice Address - Fax:978-372-6222
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN 15377-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice