Provider Demographics
NPI:1073174488
Name:WILTSIE, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WILTSIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6180 N DECATUR BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-1505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6180 N DECATUR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-1505
Practice Address - Country:US
Practice Address - Phone:702-359-3107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7235122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty