Provider Demographics
NPI:1386472207
Name:RIDDLE, ANDREW LAWRENCE (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:LAWRENCE
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18051 SW LOWER BOONES FERRY RD APT 215
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7275
Mailing Address - Country:US
Mailing Address - Phone:801-707-4012
Mailing Address - Fax:
Practice Address - Street 1:710 E FOOTHILLS DR STE 710A
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-6124
Practice Address - Country:US
Practice Address - Phone:503-379-0574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD12054122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist