Healthcare Provider Details

I. General information

NPI: 1780811984
Provider Name (Legal Business Name): RYAN HASTIIN WILSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2009
Last Update Date: 07/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6810 MENAUL BLVD NE STE B
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

101 LOS MIRADORES DR NE
RIO RANCHO NM
87124-4279
US

V. Phone/Fax

Practice location:
  • Phone: 505-872-1100
  • Fax:
Mailing address:
  • Phone: 505-427-8577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDD3162
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: