MEDICARE: NORTHSIDE DENTAL RYAN DURNER, DDS, LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1952918443
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE DENTAL RYAN DURNER, DDS, LLC

Provider Business Mailing Address
First Line	:	4254 HAMILTON AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45223-2048
Country	:	US
Telephone Number	:	513-541-5655
Fax Number	:

Provider Business Practice Location Address
First Line	:	4254 HAMILTON AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45223-2048
Country	:	US
Telephone Number	:	614-204-6818
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RYAN MATHEW DURNER
Credential	:	DDS
Telephone Number	:	614-204-6818

Provider Enumeration Date	:	09/28/2020
Last Update Date	:	05/07/2021

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