Provider Demographics
NPI:1477047082
Name:MICHAEL, DEREK RYAN (DDS)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:RYAN
Last Name:MICHAEL
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 1:2037 SE 29TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66605-2457
Mailing Address - Country:US
Mailing Address - Phone:785-267-9500
Mailing Address - Fax:785-328-4729
Practice Address - Street 1:3316 SE 28TH TERRACE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66605-2457
Practice Address - Country:US
Practice Address - Phone:785-266-9100
Practice Address - Fax:785-328-4729
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS614311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS61431OtherKANSAS DENTAL LICENSE