Provider Demographics
NPI: | 1326217001 |
---|---|
Name: | RYAN C WOODMAN DMD AND VICTORIA L MALZ DMD PLLC |
Entity Type: | Organization |
Organization Name: | RYAN C WOODMAN DMD AND VICTORIA L MALZ DMD PLLC |
Other - Org Name: | MCKEE DENTAL |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | MANAGER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | RYAN |
Authorized Official - Middle Name: | C |
Authorized Official - Last Name: | WOODMAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 704-708-4402 |
Mailing Address - Street 1: | 3320 SISKEY PKWY |
Mailing Address - Street 2: | SUITE 100 |
Mailing Address - City: | MATTHEWS |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28105-3223 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 704-708-4402 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3320 SISKEY PKWY |
Practice Address - Street 2: | SUITE 100 |
Practice Address - City: | MATTHEWS |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28105-3223 |
Practice Address - Country: | US |
Practice Address - Phone: | 704-708-4402 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2008-02-26 |
Last Update Date: | 2008-02-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |