Healthcare Provider Details

I. General information

NPI: 1972933836
Provider Name (Legal Business Name): RYAN RICHARD D.M.D , M.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 BEAVER RUIN RD NW
LILBURN GA
30047-3401
US

IV. Provider business mailing address

645 BEAVER RUIN RD NW
LILBURN GA
30047-3401
US

V. Phone/Fax

Practice location:
  • Phone: 770-448-8882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDNO1436
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: