Healthcare Provider Details

I. General information

NPI: 1700093168
Provider Name (Legal Business Name): RYAN PATRICK MCKENNA D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 NEBRASKA ST
SIOUX CITY IA
51105-1436
US

IV. Provider business mailing address

PO BOX 5410
SIOUX CITY IA
51102-5410
US

V. Phone/Fax

Practice location:
  • Phone: 712-252-2477
  • Fax:
Mailing address:
  • Phone: 712-252-2477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number08207
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: