Provider Demographics
NPI:1336677293
Name:RYAN, JENNIFER (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 LIVE OAK ST APT 6106
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-5738
Mailing Address - Country:US
Mailing Address - Phone:912-674-1930
Mailing Address - Fax:
Practice Address - Street 1:3302 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2013
Practice Address - Country:US
Practice Address - Phone:214-828-8121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0153221223X0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics