Healthcare Provider Details

I. General information

NPI: 1346397775
Provider Name (Legal Business Name): JOHN RICHARD CHIDLEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 01/11/2022
Certification Date: 01/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 TIBBETTS ST
RIVERSIDE CA
92506-2606
US

IV. Provider business mailing address

3715 TIBBETTS ST
RIVERSIDE CA
92506-2606
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-9296
  • Fax:
Mailing address:
  • Phone: 951-682-9296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number58141
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6645
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: