Provider Demographics
NPI:1073667663
Name:HUCKEBY, RYAN KEITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:KEITH
Last Name:HUCKEBY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 S HIGGINS AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4140
Mailing Address - Country:US
Mailing Address - Phone:406-728-9442
Mailing Address - Fax:
Practice Address - Street 1:1227 S HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4140
Practice Address - Country:US
Practice Address - Phone:406-728-9442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT20241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice