Provider Demographics
NPI:1578348769
Name:VILLAR, RYAN MATTHEW BUENAVENTURA (DMD)
Entity Type:Individual
Prefix:
First Name:RYAN MATTHEW
Middle Name:BUENAVENTURA
Last Name:VILLAR
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 1:250 LOG POND LN
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-1135
Mailing Address - Country:US
Mailing Address - Phone:937-479-9542
Mailing Address - Fax:
Practice Address - Street 1:3640 CROCKER DR STE 130
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-3970
Practice Address - Country:US
Practice Address - Phone:916-550-9429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1092231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty