Provider Demographics
NPI:1295182954
Name:DAVIS, RYAN JACOB (DMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JACOB
Last Name:DAVIS
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 1:2301 E ALLEGHENY AVE # 202
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4427
Mailing Address - Country:US
Mailing Address - Phone:619-532-7935
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CENTER SAN DIEGO
Practice Address - Street 2:34800 BOB WILSON DRIVE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5000
Practice Address - Country:US
Practice Address - Phone:619-532-7935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040786390200000X, 122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVAD0000Medicare UPIN