Provider Demographics
NPI:1558709527
Name:NIELSON, RYAN MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MATTHEW
Last Name:NIELSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9874 E ARIZONA DR APT 624
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-6349
Mailing Address - Country:US
Mailing Address - Phone:716-531-6189
Mailing Address - Fax:
Practice Address - Street 1:1411 FALLS AVE E STE 1000C
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3459
Practice Address - Country:US
Practice Address - Phone:208-734-7415
Practice Address - Fax:208-733-1922
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-44961223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry