Provider Demographics
NPI:1215379540
Name:BURT, RYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:BURT
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 1:148 ARBOR CT
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68108-1725
Mailing Address - Country:US
Mailing Address - Phone:801-842-6116
Mailing Address - Fax:
Practice Address - Street 1:3300 NORTH RUNNING CREEK WAY
Practice Address - Street 2:BLDG F, SUITE #101
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043
Practice Address - Country:US
Practice Address - Phone:801-766-2266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8490378-99221223P0221X
NE1121223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry