Provider Demographics
NPI:1003861287
Name:JAY, RYAN CAMPBELL (DDS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:CAMPBELL
Last Name:JAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12110 PENDLETON PIKE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236
Mailing Address - Country:US
Mailing Address - Phone:317-826-1050
Mailing Address - Fax:317-826-1065
Practice Address - Street 1:12110 PENDLETON PIKE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236
Practice Address - Country:US
Practice Address - Phone:317-826-1050
Practice Address - Fax:317-826-1065
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010606A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200460270AMedicaid
IN100071480AMedicaid