=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508154634
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN JOHN THEOBALD D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2011
-----------------------------------------------------
Last Update Date | 07/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1041 E HWY 152
-----------------------------------------------------
City | MUSTANG
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73064-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-518-4011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1041 E HWY 152
-----------------------------------------------------
City | MUSTANG
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73064-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6302
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------