Healthcare Provider Details

I. General information

NPI: 1336871920
Provider Name (Legal Business Name): RYAN KNIGHTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 S ALAMEDA BLVD
LAS CRUCES NM
88005-2818
US

IV. Provider business mailing address

605 E GARDEN AVE
SOUTH SALT LAKE UT
84106-1338
US

V. Phone/Fax

Practice location:
  • Phone: 575-526-1105
  • Fax:
Mailing address:
  • Phone: 385-722-6326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD5649
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: