Provider Demographics
NPI:1346815131
Name:RYAN, AMANDA ROSE (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:ROSE
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 1:1435 N MCCARTHY RD APT 5
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8285
Mailing Address - Country:US
Mailing Address - Phone:413-242-8142
Mailing Address - Fax:
Practice Address - Street 1:811 N LYNNDALE DR STE 1A
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3085
Practice Address - Country:US
Practice Address - Phone:920-739-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
WI1002583-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program