Provider Demographics
NPI:1386849446
Name:SMART, RYAN J (DMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:SMART
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10175 GATEWAY BLVD W STE 304
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-7618
Mailing Address - Country:US
Mailing Address - Phone:915-504-6880
Mailing Address - Fax:
Practice Address - Street 1:2585 23RD AVE S UNIT A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6172
Practice Address - Country:US
Practice Address - Phone:701-478-4404
Practice Address - Fax:701-478-4407
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND134111223S0112X, 204E00000X, 204E00000X
ND22301223S0112X
TXS0991204E00000X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMD.206018OtherLA MEDICAL LICENSE
LAS-751OtherLA RESTRICTED DENTAL LICENSE
LA2331701Medicaid