Healthcare Provider Details

I. General information

NPI: 1285640383
Provider Name (Legal Business Name): PAUL RILEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S MAPLE ST STE C
RIDGELAND MS
39157-2305
US

IV. Provider business mailing address

108 S MAPLE ST STE C
RIDGELAND MS
39157-2305
US

V. Phone/Fax

Practice location:
  • Phone: 769-567-2555
  • Fax:
Mailing address:
  • Phone: 769-567-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2359-87
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License NumberOP-6042-23
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: