Provider Demographics
NPI:1992880546
Name:RIDDLE, JEROME JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:JOHN
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 1:6345 E BELL RD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-6452
Mailing Address - Country:US
Mailing Address - Phone:480-991-4410
Mailing Address - Fax:480-948-0982
Practice Address - Street 1:6345 E BELL RD
Practice Address - Street 2:SUITE #2
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6452
Practice Address - Country:US
Practice Address - Phone:480-991-4410
Practice Address - Fax:480-948-0982
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice