Healthcare Provider Details

I. General information

NPI: 1922187020
Provider Name (Legal Business Name): MARK INGRAM RYDER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 PARNASSUS AVE ROOM C-628
SAN FRANCISCO CA
94143-2206
US

IV. Provider business mailing address

521 PARNASSUS AVE ROOM C-628
SAN FRANCISCO CA
94143-2206
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-1699
  • Fax: 415-502-4990
Mailing address:
  • Phone: 415-476-1699
  • Fax: 415-502-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberCA51446
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: