Healthcare Provider Details

I. General information

NPI: 1356884381
Provider Name (Legal Business Name): JAN-RYAN DANE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2016
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PETESA ROAD
PAGO PAGO AMERICAN SAMOA
96799
UM

IV. Provider business mailing address

PETESA ROAD
PAGO PAGO AMERICAN SAMOA
96799
UM

V. Phone/Fax

Practice location:
  • Phone: 684-699-6380
  • Fax: 684-699-6374
Mailing address:
  • Phone: 684-699-6380
  • Fax: 684-699-6374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4071-C
License Number StateAS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: