Provider Demographics
NPI:1083275820
Name:LE, RYAN (DMD, MBA, MMB)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:LE
Suffix:
Gender:M
Credentials:DMD, MBA, MMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2347 DONNINGTON LN NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-3323
Mailing Address - Country:US
Mailing Address - Phone:980-721-6170
Mailing Address - Fax:
Practice Address - Street 1:16615 RIVERSTONE WAY STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-5748
Practice Address - Country:US
Practice Address - Phone:704-542-9923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC113661223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223G0001XDental ProvidersDentistGeneral Practice