Healthcare Provider Details

I. General information

NPI: 1821915885
Provider Name (Legal Business Name): RYAN ROBERTSON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 TRIMBLE RD STE 109
COLUMBIA MO
65201-7126
US

IV. Provider business mailing address

2910 TRIMBLE RD STE 109
COLUMBIA MO
65201-7126
US

V. Phone/Fax

Practice location:
  • Phone: 573-303-5956
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2026030534
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: