Provider Demographics
NPI:1033280136
Name:KIDMAN, RYAN T (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:T
Last Name:KIDMAN
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 1:139 ALTURAS ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4309
Mailing Address - Country:US
Mailing Address - Phone:208-523-5090
Mailing Address - Fax:
Practice Address - Street 1:139 ALTURAS ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4309
Practice Address - Country:US
Practice Address - Phone:208-523-5090
Practice Address - Fax:208-895-0583
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD40061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807576700Medicaid