Healthcare Provider Details

I. General information

NPI: 1174411292
Provider Name (Legal Business Name): RYAN NIA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 S DOBSON RD STE 1
MESA AZ
85202-5657
US

IV. Provider business mailing address

11232 N 136TH PL
SCOTTSDALE AZ
85259-4647
US

V. Phone/Fax

Practice location:
  • Phone: 480-730-0500
  • Fax:
Mailing address:
  • Phone: 480-861-7002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012498
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD012498
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: