Healthcare Provider Details

I. General information

NPI: 1154408045
Provider Name (Legal Business Name): RYAN MATTHEW STUNTZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 4TH AVE NE
FARLEY IA
52046-0038
US

IV. Provider business mailing address

PO BOX 38
FARLEY IA
52046-0038
US

V. Phone/Fax

Practice location:
  • Phone: 563-744-3076
  • Fax: 563-744-3150
Mailing address:
  • Phone: 563-744-3076
  • Fax: 563-744-3150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number08322
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1775730
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerUNITED CONCORDIA
# 2
Identifier0468991
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 3
Identifier39907
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerBLUE CROSS AND BLUE SHIEL
# 4
IdentifierIA0101
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerJOHN DEERE
# 5
IdentifierP90JT0YY
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerDELTA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: