Provider Demographics
NPI:1508071705
Name:KEZELE, RYAN SCOTT (DDS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:SCOTT
Last Name:KEZELE
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 1:2991 ROSENKRANZ RD
Mailing Address - Street 2:
Mailing Address - City:TIETON
Mailing Address - State:WA
Mailing Address - Zip Code:98947-9520
Mailing Address - Country:US
Mailing Address - Phone:509-673-0190
Mailing Address - Fax:
Practice Address - Street 1:606 S 48TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3613
Practice Address - Country:US
Practice Address - Phone:509-965-3235
Practice Address - Fax:509-965-9405
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9368122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist