Provider Demographics
NPI:1407947534
Name:MACRAE, RYAN PATRICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:PATRICK
Last Name:MACRAE
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 1:635 OLD GREENVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-1219
Mailing Address - Country:US
Mailing Address - Phone:864-722-9255
Mailing Address - Fax:
Practice Address - Street 1:635 OLD GREENVILLE HWY
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1219
Practice Address - Country:US
Practice Address - Phone:864-722-9255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20-1710817OtherFEDERAL TAX ID