Provider Demographics
NPI:1962131227
Name:RIDDLE, JACOB (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
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 1:5366 ESTATE OFFICE DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0611
Mailing Address - Country:US
Mailing Address - Phone:901-682-1501
Mailing Address - Fax:
Practice Address - Street 1:5366 ESTATE OFFICE DR STE 2
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0611
Practice Address - Country:US
Practice Address - Phone:901-682-1501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4634122300000X
TN119001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1962131227OtherTYPE 1