MEDICARE: DR. AMY L RIDALL DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	18563	TX

General Provider Information

NPI Number	:	1164700852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY L RIDALL DDS

Provider Business Mailing Address
First Line	:	10080 BELLAIRE BLVD
Second Line	:	STE 210
City	:	HOUSTON
State	:	TX
Zip	:	77072-5249
Country	:	US
Telephone Number	:	281-575-0742
Fax Number	:

Provider Business Practice Location Address
First Line	:	10080 BELLAIRE BLVD
Second Line	:	STE 210
City	:	HOUSTON
State	:	TX
Zip	:	77072-5249
Country	:	US
Telephone Number	:	281-575-0742
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2011
Last Update Date	:	07/28/2011

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