Healthcare Provider Details

I. General information

NPI: 1912308123
Provider Name (Legal Business Name): RYAN BUECHELE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2014
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GREEN BAY RD USS OSBORNE BLDG 1017
NORTH CHICAGO IL
60064-3048
US

IV. Provider business mailing address

PSC 561 BOX 1877
FPO AP
96310-0019
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-3530
  • Fax:
Mailing address:
  • Phone: 315-255-8577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9053253-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: