MEDICARE: RYAN MIRCHEL D.D.S., M.D.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	D010221	AZ
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	30 024690	OH
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	25908	TX

General Provider Information

NPI Number	:	1285952895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN MIRCHEL D.D.S., M.D.

Provider Business Mailing Address
First Line	:	539 W COMMERCE ST STE 5577
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-1953
Country	:	US
Telephone Number	:	469-278-4323
Fax Number	:

Provider Business Practice Location Address
First Line	:	539 W COMMERCE ST STE 5577
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-1953
Country	:	US
Telephone Number	:	469-278-4323
Fax Number	:

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

Provider Enumeration Date	:	05/06/2010
Last Update Date	:	01/22/2022

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