=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750874178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN MAX HILLS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2018
-----------------------------------------------------
Last Update Date | 06/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1317 PINE AVE
-----------------------------------------------------
City | ALMA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48801-1242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-463-4711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11670 E TAMARACK RD
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48877-9512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-304-0120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901022663
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------