Healthcare Provider Details

I. General information

NPI: 1245689033
Provider Name (Legal Business Name): RYAN HEASLEY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3480 BOB WILSON DR 3480 BOB WILSON DRIVE
SAN DIEGO CA
92134-5000
US

IV. Provider business mailing address

2565 SAN JUAN ST
COUPEVILLE WA
98239-9765
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-7935
  • Fax:
Mailing address:
  • Phone: 814-657-3585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS041011
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: