MEDICARE: JONATHAN RYAN

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	2104851114	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215320494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN RYAN

Provider Business Mailing Address
First Line	:	5415 W HARMON AVE UNIT 2086
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-7022
Country	:	US
Telephone Number	:	702-581-6482
Fax Number	:

Provider Business Practice Location Address
First Line	:	5415 W HARMON AVE UNIT 2086
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-7022
Country	:	US
Telephone Number	:	702-581-6482
Fax Number	:

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

Provider Enumeration Date	:	03/11/2015
Last Update Date	:	03/11/2015

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Directions to “ JONATHAN RYAN ” Practice Location

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