Healthcare Provider Details

I. General information

NPI: 1154872646
Provider Name (Legal Business Name): RENAISSANCE DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W WILLIAMS STREET SUITE 240
APEX NC
27502
US

IV. Provider business mailing address

800 W WILLIAMS STREET SUITE 240
APEX NC
27502
US

V. Phone/Fax

Practice location:
  • Phone: 919-323-8444
  • Fax:
Mailing address:
  • Phone: 919-323-8444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9343
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: RYLAN J HANSEN
Title or Position: DENTIST
Credential: DDS
Phone: 919-363-8444