Basic Information
| Provider Information | |||||||||
| NPI: | 1841711264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDDLE | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4996 MIRAMAR DR UNIT 6103 | ||||||||
| Address2: | |||||||||
| City: | MADEIRA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337083436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576470530 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8640 E STATE ROAD 70 STE D | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414623706 | ||||||||
| FaxNumber: | 9417270374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2017 | ||||||||
| LastUpdateDate: | 06/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN23217 | FL | N | Dental Providers | Dentist | General Practice | 1223G0001X | 1741 | FL | Y | Dental Providers | Dentist | General Practice |
No ID Information.