Provider Demographics
NPI:1346397775
Name:CHIDLEY, JOHN RICHARD (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:CHIDLEY
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 1:3715 TIBBETTS ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2606
Mailing Address - Country:US
Mailing Address - Phone:951-682-9296
Mailing Address - Fax:
Practice Address - Street 1:3715 TIBBETTS ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2606
Practice Address - Country:US
Practice Address - Phone:951-682-9296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA581411223G0001X
NE6645122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN