Provider Demographics
NPI:1225326747
Name:SMITH, RYAN DOUGLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:DOUGLAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 E 3RD S
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-1809
Mailing Address - Country:US
Mailing Address - Phone:208-624-4322
Mailing Address - Fax:208-624-4634
Practice Address - Street 1:24 E 3RD S
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:ID
Practice Address - Zip Code:83445-1809
Practice Address - Country:US
Practice Address - Phone:208-624-4322
Practice Address - Fax:208-624-4634
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-43641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice