Healthcare Provider Details

I. General information

NPI: 1891133690
Provider Name (Legal Business Name): RYAN REOPELLE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 09/27/2021
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 COLONIAL AVE
ROANOKE VA
24018-4004
US

IV. Provider business mailing address

3650 COLONIAL AVE
ROANOKE VA
24018-4004
US

V. Phone/Fax

Practice location:
  • Phone: 540-989-3639
  • Fax:
Mailing address:
  • Phone: 540-989-3639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN014934
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: