Provider Demographics
NPI:1699349118
Name:RIDENHOUR, NICK (DDS)
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:RIDENHOUR
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 1:15991 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2446
Mailing Address - Country:US
Mailing Address - Phone:636-227-2580
Mailing Address - Fax:
Practice Address - Street 1:15991 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2446
Practice Address - Country:US
Practice Address - Phone:636-227-2580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190332531223G0001X
MO20210177941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice