1043315302 NPI number — RAYNARD RILEY DDS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043315302 NPI number — RAYNARD RILEY DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAYNARD RILEY DDS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PATIENT FIRST DENTISTRY OF SUMMIT
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043315302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
475 SPRINGFIELD AVE
Provider Second Line Business Mailing Address:
SUIT 210
Provider Business Mailing Address City Name:
SUMMIT
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-273-5656
Provider Business Mailing Address Fax Number:
908-273-5661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
475 SPRINGFIELD AVE
Provider Second Line Business Practice Location Address:
SUIT 210
Provider Business Practice Location Address City Name:
SUMMIT
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-273-5656
Provider Business Practice Location Address Fax Number:
908-273-5661
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RILEY
Authorized Official First Name:
RAYNARD
Authorized Official Middle Name:
OTIS
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
908-273-5656

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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