Provider Demographics
NPI:1376859124
Name:JERGENSEN, RYAN W (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:W
Last Name:JERGENSEN
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 1:2243 MOWRY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1630
Mailing Address - Country:US
Mailing Address - Phone:510-797-8991
Mailing Address - Fax:510-797-8280
Practice Address - Street 1:2243 MOWRY AVE STE B
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1630
Practice Address - Country:US
Practice Address - Phone:510-797-8991
Practice Address - Fax:510-797-8280
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA594841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice