Healthcare Provider Details

I. General information

NPI: 1730101767
Provider Name (Legal Business Name): EDWIN J RILEY III DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 HAWTHORNE PL SUITE 102
BOSTON MA
02114-2336
US

IV. Provider business mailing address

10 HAWTHORNE PL SUITE 102
BOSTON MA
02114-2336
US

V. Phone/Fax

Practice location:
  • Phone: 617-723-4032
  • Fax: 617-723-4059
Mailing address:
  • Phone: 617-723-4032
  • Fax: 617-723-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number12185
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: