Provider Demographics
NPI:1568895977
Name:RYAN, KEVIN WILLIAM (DMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WILLIAM
Last Name:RYAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 KEILY STREET
Mailing Address - Street 2:BUMED CENTRALIZED CREDENTIAL & PRIVILEGING DIRECTORATE
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212
Mailing Address - Country:US
Mailing Address - Phone:757-953-7011
Mailing Address - Fax:
Practice Address - Street 1:554 KEILY STREET
Practice Address - Street 2:BUMED CENTRALIZED CREDENTIAL & PRIVILEGING DIRECTORATE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212
Practice Address - Country:US
Practice Address - Phone:757-953-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856197122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist