Provider Demographics
NPI:1184644171
Name:RYAN, LISA A (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:RYAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 N SWALL DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1712
Mailing Address - Country:US
Mailing Address - Phone:310-247-8750
Mailing Address - Fax:310-278-9124
Practice Address - Street 1:9201 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90069
Practice Address - Country:US
Practice Address - Phone:310-247-8750
Practice Address - Fax:310-278-9124
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA366061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA59-3812730OtherTAX ID NUMBER