Provider Demographics
NPI:1295917110
Name:TIM RIEKE DDS LLC
Entity type:Organization
Organization Name:TIM RIEKE DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:J
Authorized Official - Last Name:RIEKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-634-3115
Mailing Address - Street 1:1312 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109
Mailing Address - Country:US
Mailing Address - Phone:573-634-3115
Mailing Address - Fax:573-634-2381
Practice Address - Street 1:1312 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109
Practice Address - Country:US
Practice Address - Phone:573-634-3115
Practice Address - Fax:573-634-2381
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIM RIEKE DDS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0136811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty