Healthcare Provider Details

I. General information

NPI: 1932454030
Provider Name (Legal Business Name): RYAN D WOMACK MD DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 YAUGER WAY SW SUITE A
OLYMPIA WA
98502-8139
US

IV. Provider business mailing address

400 YAUGER WAY SW SUITE A
OLYMPIA WA
98502-8139
US

V. Phone/Fax

Practice location:
  • Phone: 360-754-9444
  • Fax: 360-754-8335
Mailing address:
  • Phone: 360-754-9444
  • Fax: 360-754-8335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberDE.60280647
License Number StateWA

VIII. Authorized Official

Name: RYAN DAVID WOMACK
Title or Position: OWNER
Credential: MD, DDS
Phone: 360-754-9444