Healthcare Provider Details

I. General information

NPI: 1417958653
Provider Name (Legal Business Name): RYAN DAVID SPARKS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 NW ROLLING GREEN DR
CORVALLIS OR
97330-3519
US

IV. Provider business mailing address

2635 NW ROLLING GREEN DR
CORVALLIS OR
97330-3519
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-9322
  • Fax: 541-754-4940
Mailing address:
  • Phone: 541-754-9322
  • Fax: 541-754-4940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7602
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: