Healthcare Provider Details

I. General information

NPI: 1922465053
Provider Name (Legal Business Name): RYAN BAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2016
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27180 NEWPORT RD STE 3
MENIFEE CA
92584-7389
US

IV. Provider business mailing address

14591 NEWPORT AVE STE 108
TUSTIN CA
92780-6026
US

V. Phone/Fax

Practice location:
  • Phone: 951-672-1666
  • Fax:
Mailing address:
  • Phone: 949-771-7234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number64066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: