Provider Demographics
NPI:1073999777
Name:PAYNE, RYAN STEVEN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:STEVEN
Last Name:PAYNE
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 1:4TH & INNER LOOP ROAD
Mailing Address - Street 2:BLDG 171
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310
Mailing Address - Country:US
Mailing Address - Phone:760-383-5289
Mailing Address - Fax:
Practice Address - Street 1:4TH & INNER LOOP ROAD
Practice Address - Street 2:BLDG 171
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:719-526-5537
Practice Address - Fax:706-787-2082
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-46561223G0001X
NVS2-167C1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice