Healthcare Provider Details

I. General information

NPI: 1386472207
Provider Name (Legal Business Name): ANDREW LAWRENCE RIDDLE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2267 NW PETTYGROVE ST
PORTLAND OR
97210-2760
US

IV. Provider business mailing address

2120 SW DOLPH CT
PORTLAND OR
97219-4175
US

V. Phone/Fax

Practice location:
  • Phone: 503-224-6317
  • Fax:
Mailing address:
  • Phone: 801-707-4012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD12054
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: