Provider Demographics
NPI:1083086524
Name:ANDERSON, RYAN TAYLOR (DDS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:TAYLOR
Last Name:ANDERSON
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 1:13 EAST 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050
Mailing Address - Country:US
Mailing Address - Phone:719-384-9442
Mailing Address - Fax:719-384-9446
Practice Address - Street 1:13 EAST 4TH STREET
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050
Practice Address - Country:US
Practice Address - Phone:719-384-9442
Practice Address - Fax:719-384-9446
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002026591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice