Provider Demographics
NPI:1306391016
Name:COSTNER, RYAN (DDS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:COSTNER
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 1:12450 CLEVELAND RD STE 203
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-8355
Mailing Address - Country:US
Mailing Address - Phone:919-277-7957
Mailing Address - Fax:
Practice Address - Street 1:598 E JACKSON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:NC
Practice Address - Zip Code:28339-9632
Practice Address - Country:US
Practice Address - Phone:910-230-5472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC108731223G0001X
IA401611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice