Healthcare Provider Details

I. General information

NPI: 1457568891
Provider Name (Legal Business Name): CRAIG MARTIN RIRIE D.D.S. M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3610 N. UNIVERSITY AVE. 150
PROVO UT
84604
US

IV. Provider business mailing address

3610 N UNIVERSITY AVE 150
PROVO UT
84604-4437
US

V. Phone/Fax

Practice location:
  • Phone: 801-356-2226
  • Fax:
Mailing address:
  • Phone: 801-356-2226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number23082
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: