Provider Demographics
NPI:1225103880
Name:RYAN, JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:RYAN
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 1:5303 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-3800
Mailing Address - Country:US
Mailing Address - Phone:517-887-4423
Mailing Address - Fax:
Practice Address - Street 1:1409 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1119
Practice Address - Country:US
Practice Address - Phone:574-936-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010965A122300000X
MI2901017824122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12010965AOtherSTATE LICENSE
MI744847822Medicaid