Healthcare Provider Details

I. General information

NPI: 1801616735
Provider Name (Legal Business Name): MICHAEL JOHN RILEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10240 COMMERCE AVE APT 209
TUJUNGA CA
91042-3588
US

IV. Provider business mailing address

10240 COMMERCE AVE APT 209
TUJUNGA CA
91042-3588
US

V. Phone/Fax

Practice location:
  • Phone: 772-418-6564
  • Fax:
Mailing address:
  • Phone: 772-418-6564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS110884
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: