Provider Demographics
NPI:1487712881
Name:RILEY, ROGER E (DDS)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:E
Last Name:RILEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26302 LA PAZ RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5327
Mailing Address - Country:US
Mailing Address - Phone:949-448-7667
Mailing Address - Fax:949-586-6525
Practice Address - Street 1:26302 LA PAZ RD STE 102
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5327
Practice Address - Country:US
Practice Address - Phone:949-448-7667
Practice Address - Fax:949-586-6525
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14162122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist