Provider Demographics
NPI:1306001854
Name:BOLES, RYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:BOLES
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 1:701 SHEDECK PKWY
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-6021
Mailing Address - Country:US
Mailing Address - Phone:405-350-1133
Mailing Address - Fax:405-350-1139
Practice Address - Street 1:701 SHEDECK PKWY
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6021
Practice Address - Country:US
Practice Address - Phone:405-350-1133
Practice Address - Fax:405-350-1139
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6069122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist