MEDICARE: RYAN HILLSTEAD DMD

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	1223G0001X	General Practice Dentistry	101345	CA

General Provider Information

NPI Number	:	1760985832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN HILLSTEAD DMD

Provider Business Mailing Address
First Line	:	574 3RD ST W
Second Line	:
City	:	SONOMA
State	:	CA
Zip	:	95476-6502
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	574 3RD ST W
Second Line	:
City	:	SONOMA
State	:	CA
Zip	:	95476-6502
Country	:	US
Telephone Number	:	707-996-0813
Fax Number	:

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

Provider Enumeration Date	:	03/14/2018
Last Update Date	:	03/14/2018

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