MEDICARE: DR. ROBERT DAVID RIDEAU 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	1223G0001X	General Practice Dentistry	32170	CA

General Provider Information

NPI Number	:	1619027273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT DAVID RIDEAU DDS

Provider Business Mailing Address
First Line	:	66 BOVET RD
Second Line	:	SUITE 105
City	:	SAN MATEO
State	:	CA
Zip	:	94402-3125
Country	:	US
Telephone Number	:	650-627-8191
Fax Number	:	650-627-8192

Provider Business Practice Location Address
First Line	:	66 BOVET RD
Second Line	:	SUITE 105
City	:	SAN MATEO
State	:	CA
Zip	:	94402-3125
Country	:	US
Telephone Number	:	650-627-8191
Fax Number	:	650-627-8192

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

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	07/08/2007

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