Provider Demographics
NPI:1073297750
Name:DEMENT, RYAN (OD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DEMENT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9979 WINGHAVEN BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3628
Mailing Address - Country:US
Mailing Address - Phone:636-695-8555
Mailing Address - Fax:
Practice Address - Street 1:3821 VETERANS MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-6416
Practice Address - Country:US
Practice Address - Phone:636-928-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023020825152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist