Healthcare Provider Details

I. General information

NPI: 1912148305
Provider Name (Legal Business Name): RICHARD E RIDGLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 WELCH RD STE H
PALO ALTO CA
94304-1602
US

IV. Provider business mailing address

777 WELCH RD STE H
PALO ALTO CA
94304-1602
US

V. Phone/Fax

Practice location:
  • Phone: 650-326-7257
  • Fax: 650-326-2461
Mailing address:
  • Phone: 650-326-7257
  • Fax: 650-326-2461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number23371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: