Provider Demographics
NPI:1578606901
Name:STREET, RYAN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:A
Last Name:STREET
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 W 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-3900
Mailing Address - Country:US
Mailing Address - Phone:806-355-7463
Mailing Address - Fax:806-355-6014
Practice Address - Street 1:4525 VAN WINKLE DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119
Practice Address - Country:US
Practice Address - Phone:806-355-7463
Practice Address - Fax:806-355-6014
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX218341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice