Healthcare Provider Details

I. General information

NPI: 1417928136
Provider Name (Legal Business Name): RYAN REPOSA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6980 MESA RIDGE PKWY SUITE 200
FOUNTAIN CO
80817-1533
US

IV. Provider business mailing address

6980 MESA RIDGE PKWY SUITE 200
FOUNTAIN CO
80817-1533
US

V. Phone/Fax

Practice location:
  • Phone: 719-392-4231
  • Fax: 719-392-9096
Mailing address:
  • Phone: 719-392-4231
  • Fax: 719-392-9096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8909
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: