MEDICARE: RILEY FAMILY DENTISTRY PLLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1356055529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RILEY FAMILY DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	101 STATE AVE
Second Line	:
City	:	GLASGOW
State	:	KY
Zip	:	42141-1448
Country	:	US
Telephone Number	:	270-651-5939
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 STATE AVE
Second Line	:
City	:	GLASGOW
State	:	KY
Zip	:	42141-1448
Country	:	US
Telephone Number	:	270-651-5939
Fax Number	:	270-651-7062

Authorized Official
Title or Position	:	FRONT LINE ADMIN
Name	:	MRS. JENNY DARST
Credential	:
Telephone Number	:	270-651-5939

Provider Enumeration Date	:	01/11/2023
Last Update Date	:	01/11/2023

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