Provider Demographics
NPI:1689826240
Name:WELLER, RYAN (RDHAP)
Entity Type:Individual
Prefix:MRS
First Name:RYAN
Middle Name:
Last Name:WELLER
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0279
Mailing Address - Country:US
Mailing Address - Phone:909-353-4154
Mailing Address - Fax:
Practice Address - Street 1:11092 ANDERSON STREET
Practice Address - Street 2:LLU SCHOOL OF DENTISTRY
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-0001
Practice Address - Country:US
Practice Address - Phone:909-558-4613
Practice Address - Fax:909-558-4192
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH 22326124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDH 22326OtherSTATE LICENSE