Provider Demographics
NPI:1093899122
Name:WOOD, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WOOD
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 1:1200 SHERWOOD PARK DR NE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3445
Mailing Address - Country:US
Mailing Address - Phone:770-532-4555
Mailing Address - Fax:
Practice Address - Street 1:1200 SHERWOOD PARK DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3445
Practice Address - Country:US
Practice Address - Phone:770-532-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0131241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice