Healthcare Provider Details

I. General information

NPI: 1811379530
Provider Name (Legal Business Name): RYAN JOSEPH CICERO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34225 N 27TH DRIVE BLDG 5 STE 240
PHOENIX AZ
85085
US

IV. Provider business mailing address

34225 N 27TH DRIVE BLDG 5 STE 241
PHOENIX AZ
85085-6019
US

V. Phone/Fax

Practice location:
  • Phone: 623-322-1538
  • Fax:
Mailing address:
  • Phone: 623-439-2280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD009230
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9230
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: