Provider Demographics
NPI:1215185814
Name:WILSON, RYAN NEIL (DDS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:NEIL
Last Name:WILSON
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 1:3143 E 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-4815
Mailing Address - Country:US
Mailing Address - Phone:509-536-5900
Mailing Address - Fax:509-534-1015
Practice Address - Street 1:3143 E 29TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-4815
Practice Address - Country:US
Practice Address - Phone:509-536-5900
Practice Address - Fax:509-534-1015
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57421122300000X
WADE60076403122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5059522Medicaid