Healthcare Provider Details

I. General information

NPI: 1053785071
Provider Name (Legal Business Name): RYAN HULSHOF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2015
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E 16TH ST UNIT 1001
CHICAGO IL
60616-5142
US

IV. Provider business mailing address

50 E 16TH ST UNIT 1001
CHICAGO IL
60616-5142
US

V. Phone/Fax

Practice location:
  • Phone: 712-441-0091
  • Fax:
Mailing address:
  • Phone: 712-441-0091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019030352
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: