MEDICARE: DR. RYAN NEWELL BULLEN DMD, DHSC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8693	AZ

General Provider Information

NPI Number	:	1457786741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN NEWELL BULLEN DMD, DHSC

Provider Business Mailing Address
First Line	:	335 W BELLO VISTA PLZ
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409-2975
Country	:	US
Telephone Number	:	801-787-6883
Fax Number	:

Provider Business Practice Location Address
First Line	:	1845 MCCULLOCH BLVD N STE A1
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5722
Country	:	US
Telephone Number	:	928-855-7700
Fax Number	:

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

Provider Enumeration Date	:	09/05/2013
Last Update Date	:	09/05/2013

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