Provider Demographics
NPI:1588786651
Name:RIDDLE, FRED ALBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:ALBERT
Last Name:RIDDLE
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 1:108 EAST MARKET ST
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-1733
Mailing Address - Country:US
Mailing Address - Phone:319-338-1171
Mailing Address - Fax:319-337-8350
Practice Address - Street 1:108 EAST MARKET ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-1733
Practice Address - Country:US
Practice Address - Phone:319-338-1171
Practice Address - Fax:319-337-8350
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA57181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice