Healthcare Provider Details

I. General information

NPI: 1588643068
Provider Name (Legal Business Name): RYAN MICHAEL BAILEY DDS,MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10703 SPOTSYLVANIA AVE SUITE 101
FREDERICKSBURG VA
22408-2692
US

IV. Provider business mailing address

10703 SPOTSYLVANIA AVE SUITE 101
FREDERICKSBURG VA
22408-2692
US

V. Phone/Fax

Practice location:
  • Phone: 540-710-8880
  • Fax: 540-710-8884
Mailing address:
  • Phone: 540-710-8880
  • Fax: 540-710-8884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019026604
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0438000230
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: