MEDICARE: DR. GARY LYNN RIDDLE DDS

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	13773	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942361365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY LYNN RIDDLE DDS

Provider Business Mailing Address
First Line	:	1420 MAIN ST
Second Line	:
City	:	SCOTT CITY
State	:	MO
Zip	:	63780-1936
Country	:	US
Telephone Number	:	573-264-2020
Fax Number	:	573-264-2678

Provider Business Practice Location Address
First Line	:	1420 MAIN ST
Second Line	:
City	:	SCOTT CITY
State	:	MO
Zip	:	63780-1936
Country	:	US
Telephone Number	:	573-264-2020
Fax Number	:	573-264-2678

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

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	01/10/2012

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