Provider Demographics
NPI:1366527632
Name:JEROME RIDDLE DDS PC
Entity type:Organization
Organization Name:JEROME RIDDLE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-991-4410
Mailing Address - Street 1:6345 E BELL RD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-6452
Mailing Address - Country:US
Mailing Address - Phone:480-991-4410
Mailing Address - Fax:480-948-0982
Practice Address - Street 1:6345 E BELL RD
Practice Address - Street 2:SUITE #2
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6452
Practice Address - Country:US
Practice Address - Phone:480-991-4410
Practice Address - Fax:480-948-0982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty