Provider Demographics
NPI:1447383302
Name:RILEY, TERRANCE P (DDS)
Entity type:Individual
Prefix:
First Name:TERRANCE
Middle Name:P
Last Name:RILEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2441 CORAL CT STE 2
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2872
Mailing Address - Country:US
Mailing Address - Phone:319-337-2599
Mailing Address - Fax:319-337-2599
Practice Address - Street 1:5345 SPRING ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2764
Practice Address - Country:US
Practice Address - Phone:319-337-2599
Practice Address - Fax:319-545-2020
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08390122300000X, 1223G0001X, 1223X2210X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No1223X2210XDental ProvidersDentistOrofacial Pain
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA6681240001Medicare NSC