Healthcare Provider Details

I. General information

NPI: 1386849446
Provider Name (Legal Business Name): RYAN J SMART DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2585 23RD AVE S UNIT A
FARGO ND
58103-6172
US

IV. Provider business mailing address

10175 GATEWAY BLVD W STE 304
EL PASO TX
79925-7618
US

V. Phone/Fax

Practice location:
  • Phone: 701-478-4404
  • Fax: 701-478-4407
Mailing address:
  • Phone: 915-504-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13411
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2230
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number13411
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: