MEDICARE: DR. RYAN REPOSA DMD

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	1223G0001X	General Practice Dentistry	8909	CO

General Provider Information

NPI Number	:	1417928136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN REPOSA DMD

Provider Business Mailing Address
First Line	:	6980 MESA RIDGE PKWY
Second Line	:	SUITE 200
City	:	FOUNTAIN
State	:	CO
Zip	:	80817-1533
Country	:	US
Telephone Number	:	719-392-4231
Fax Number	:	719-392-9096

Provider Business Practice Location Address
First Line	:	6980 MESA RIDGE PKWY
Second Line	:	SUITE 200
City	:	FOUNTAIN
State	:	CO
Zip	:	80817-1533
Country	:	US
Telephone Number	:	719-392-4231
Fax Number	:	719-392-9096

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	07/08/2007

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