Provider Demographics
NPI:1629358429
Name:RYNEARSON, R. DAVID (DDS, MS)
Entity Type:Individual
Prefix:
First Name:R. DAVID
Middle Name:
Last Name:RYNEARSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11401 HEACOCK ST STE 300
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7908
Mailing Address - Country:US
Mailing Address - Phone:951-247-7228
Mailing Address - Fax:
Practice Address - Street 1:11401 HEACOCK ST STE 300
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-7908
Practice Address - Country:US
Practice Address - Phone:951-247-7228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics