Provider Demographics
NPI:1326056300
Name:MOFFAT, RYAN C (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:C
Last Name:MOFFAT
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:PO BOX 830
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020
Mailing Address - Country:US
Mailing Address - Phone:801-495-1610
Mailing Address - Fax:801-495-1631
Practice Address - Street 1:114 E 12450 S
Practice Address - Street 2:SUITE 200
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020
Practice Address - Country:US
Practice Address - Phone:801-495-1610
Practice Address - Fax:801-495-1631
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT58324601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ960296OtherAHCCCS
1749089OtherUNITED CONCORDIA
58324609900001OtherBLUE CROSS