Provider Demographics
NPI:1306220652
Name:MARTIN, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 NW SHEVLIN PARK RD STE 140
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7133
Mailing Address - Country:US
Mailing Address - Phone:844-929-3636
Mailing Address - Fax:
Practice Address - Street 1:2225 NW SHEVLIN PARK RD STE 140
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7133
Practice Address - Country:US
Practice Address - Phone:844-929-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD113031223E0200X
AZIN PROCESS122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty