Healthcare Provider Details

I. General information

NPI: 1053537571
Provider Name (Legal Business Name): RYAN FREDERICK VANMOORLEHEM D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 N 100 E SUITE 3
SPANISH FORK UT
84660-1241
US

IV. Provider business mailing address

826 N 100 E SUITE 3
SPANISH FORK UT
84660-1241
US

V. Phone/Fax

Practice location:
  • Phone: 801-504-6070
  • Fax: 801-504-6068
Mailing address:
  • Phone: 801-504-6070
  • Fax: 801-504-6068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number5171989
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: