Provider Demographics
NPI:1316178338
Name:BUCKWALTER, RYAN MARK (DDS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MARK
Last Name:BUCKWALTER
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 1:1420 GREENBRIER PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-1696
Mailing Address - Country:US
Mailing Address - Phone:434-973-2224
Mailing Address - Fax:434-973-2361
Practice Address - Street 1:1420 GREENBRIER PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-1696
Practice Address - Country:US
Practice Address - Phone:434-973-2224
Practice Address - Fax:434-973-2361
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-07
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413341122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist