MEDICARE: DR. KEVIN A RYAN DDS

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	0401005945	VA

General Provider Information

NPI Number	:	1790809663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN A RYAN DDS

Provider Business Mailing Address
First Line	:	5312 CAROLINA PL
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22151-4401
Country	:	US
Telephone Number	:	703-354-8811
Fax Number	:	703-354-1768

Provider Business Practice Location Address
First Line	:	5312 CAROLINA PL
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22151-4401
Country	:	US
Telephone Number	:	703-354-8811
Fax Number	:	703-354-1768

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

Provider Enumeration Date	:	03/18/2007
Last Update Date	:	07/08/2007

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