Provider Demographics
NPI:1841489150
Name:RIDDER ORTHODONTICS OF FORT WORTH PC
Entity type:Organization
Organization Name:RIDDER ORTHODONTICS OF FORT WORTH PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:RIDDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:817-741-0484
Mailing Address - Street 1:12717 CREAMELLO AVE
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-1160
Mailing Address - Country:US
Mailing Address - Phone:817-741-0484
Mailing Address - Fax:
Practice Address - Street 1:12453 TIMBERLAND BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248
Practice Address - Country:US
Practice Address - Phone:817-741-0484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty