Provider Demographics
NPI:1144367087
Name:RIVERSIDE DENTAL CLINIC, P.C.
Entity type:Organization
Organization Name:RIVERSIDE DENTAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYUNG
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-820-0370
Mailing Address - Street 1:1311 E BELT LINE RD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-6289
Mailing Address - Country:US
Mailing Address - Phone:972-820-0370
Mailing Address - Fax:
Practice Address - Street 1:1311 E BELT LINE RD
Practice Address - Street 2:SUITE #3
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-6289
Practice Address - Country:US
Practice Address - Phone:972-820-0370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty