Provider Demographics
NPI:1023559069
Name:RYAN CARPENTER DMD PC
Entity Type:Organization
Organization Name:RYAN CARPENTER DMD PC
Other - Org Name:POWELL VALLEY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-539-0595
Mailing Address - Street 1:PO BOX 916
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-0916
Mailing Address - Country:US
Mailing Address - Phone:503-539-0595
Mailing Address - Fax:
Practice Address - Street 1:2517 SE 179TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-1035
Practice Address - Country:US
Practice Address - Phone:503-761-4001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD86181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty