MEDICARE: DR. RYAN DOUGLAS REYES DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	FR4281933	CA

General Provider Information

NPI Number	:	1043513351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN DOUGLAS REYES DDS

Provider Business Mailing Address
First Line	:	4778 MUIR AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-2218
Country	:	US
Telephone Number	:	858-373-8855
Fax Number	:

Provider Business Practice Location Address
First Line	:	4778 MUIR AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-2218
Country	:	US
Telephone Number	:	858-373-8855
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2010
Last Update Date	:	05/06/2016

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