Provider Demographics
NPI:1558042614
Name:SMITH, RYAN REAY
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:REAY
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5109 NORTHWAY DR APT 802
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1439
Mailing Address - Country:US
Mailing Address - Phone:832-527-6005
Mailing Address - Fax:
Practice Address - Street 1:4800 NE STALLINGS DR STE 102
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1251
Practice Address - Country:US
Practice Address - Phone:936-305-7695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX398831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty