MEDICARE: DR. JOHN WADE RILEY DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	Z28211	SC

General Provider Information

NPI Number	:	1669524260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN WADE RILEY DMD

Provider Business Mailing Address
First Line	:	PO BOX 659
Second Line	:
City	:	WILLISTON
State	:	SC
Zip	:	29853-0659
Country	:	US
Telephone Number	:	803-266-7246
Fax Number	:	803-266-3403

Provider Business Practice Location Address
First Line	:	10 ROUNDTREE ST.
Second Line	:
City	:	WILLISTON
State	:	SC
Zip	:	29853-0659
Country	:	US
Telephone Number	:	803-266-7246
Fax Number	:	803-266-3403

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	07/08/2007

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