=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477854396
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN LEVI ULIBARRI DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2010
-----------------------------------------------------
Last Update Date | 07/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4745 E BOARDWALK DR UNIT C2
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80525-3769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-224-5599
-----------------------------------------------------
Fax | 970-224-0731
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4745 BOARDWALK DR UNIT C2
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80525-3769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-224-5599
-----------------------------------------------------
Fax | 970-224-5599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DEN00202189
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DEN.00202189
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------