Provider Demographics
NPI:1710136585
Name:BRADEN, RYAN THOMAS
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:THOMAS
Last Name:BRADEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:THOMAS
Other - Last Name:BRADEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:101 BROAD ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2000
Mailing Address - Country:US
Mailing Address - Phone:262-248-0120
Mailing Address - Fax:262-249-0140
Practice Address - Street 1:101 BROAD ST
Practice Address - Street 2:SUITE 203
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2000
Practice Address - Country:US
Practice Address - Phone:262-248-0120
Practice Address - Fax:262-249-0140
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI59081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice