Provider Demographics
NPI:1679829923
Name:ANDERSON, RYAN GREG (DMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:GREG
Last Name:ANDERSON
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 1:520 E VINE ST UNIT 484
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2300
Mailing Address - Country:US
Mailing Address - Phone:817-318-6329
Mailing Address - Fax:
Practice Address - Street 1:2771 E BROAD ST STE 221
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9157
Practice Address - Country:US
Practice Address - Phone:435-531-6385
Practice Address - Fax:817-473-2251
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28081122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist