MEDICARE: DR. RYAN A STREET 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	1223G0001X	General Practice Dentistry	21834	TX

General Provider Information

NPI Number	:	1578606901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN A STREET DDS

Provider Business Mailing Address
First Line	:	7201 W 34TH AVE
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79109-3900
Country	:	US
Telephone Number	:	806-355-7463
Fax Number	:	806-355-6014

Provider Business Practice Location Address
First Line	:	4525 VAN WINKLE DR
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79119
Country	:	US
Telephone Number	:	806-355-7463
Fax Number	:	806-355-6014

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	08/11/2011

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