Healthcare Provider Details

I. General information

NPI: 1942399159
Provider Name (Legal Business Name): RYAN M. DIEPENBROCK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7845 CARNEGIE BLVD STE A
FORT WAYNE IN
46804-5792
US

IV. Provider business mailing address

101 BODIN CIR
FAIRFIELD CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 260-423-2340
  • Fax:
Mailing address:
  • Phone: 707-423-7085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number63091
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30-022164
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number12012587A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: