MEDICARE: RYAN JAMES CONLON

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	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	39977	TX

General Provider Information

NPI Number	:	1063197499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN JAMES CONLON

Provider Business Mailing Address
First Line	:	1033 BRODERICK ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94115-3902
Country	:	US
Telephone Number	:	415-601-9973
Fax Number	:

Provider Business Practice Location Address
First Line	:	1033 BRODERICK ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94115-3902
Country	:	US
Telephone Number	:	415-601-9973
Fax Number	:

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

Provider Enumeration Date	:	06/21/2023
Last Update Date	:	09/01/2023

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