Healthcare Provider Details

I. General information

NPI: 1487059721
Provider Name (Legal Business Name): RYAN GOERGEN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 LINDELL BLVD
SAINT LOUIS MO
63108-3201
US

IV. Provider business mailing address

3143 EVERGLADE AVE
WOODRIDGE IL
60517-3316
US

V. Phone/Fax

Practice location:
  • Phone: 314-535-7701
  • Fax:
Mailing address:
  • Phone: 630-291-0957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2014038355
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: