Provider Demographics
NPI:1710157250
Name:J.D RYAN DDS, INC.
Entity Type:Organization
Organization Name:J.D RYAN DDS, INC.
Other - Org Name:SMILEMAKERS FAMILY DENTAL GROUP WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPANY MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:AVERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-276-6226
Mailing Address - Street 1:779 HARRISBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43223-2113
Mailing Address - Country:US
Mailing Address - Phone:614-276-6226
Mailing Address - Fax:614-276-6129
Practice Address - Street 1:779 HARRISBURG PIKE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-2113
Practice Address - Country:US
Practice Address - Phone:614-276-6226
Practice Address - Fax:614-276-6129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300139691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0222968Medicaid