Provider Demographics
NPI:1538130752
Name:JACK, RYAN MICHAEL (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MICHAEL
Last Name:JACK
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8580 SCARBOROUGH DR
Mailing Address - Street 2:#200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7583
Mailing Address - Country:US
Mailing Address - Phone:719-282-6600
Mailing Address - Fax:
Practice Address - Street 1:8580 SCARBOROUGH DR
Practice Address - Street 2:#200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7583
Practice Address - Country:US
Practice Address - Phone:719-282-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2010-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-35851223E0200X
FLDN181771223E0200X
CO100461223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics