Provider Demographics
NPI:1063490480
Name:ROSS, RYAN LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:LEE
Last Name:ROSS
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 1:497 E US HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-7745
Mailing Address - Country:US
Mailing Address - Phone:812-443-2541
Mailing Address - Fax:812-446-1045
Practice Address - Street 1:497 E US HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-7745
Practice Address - Country:US
Practice Address - Phone:812-443-2541
Practice Address - Fax:812-446-1045
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009777122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist