Provider Demographics
NPI:1710290663
Name:O'MALLEY, RYAN (DDS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 SE MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-2674
Mailing Address - Country:US
Mailing Address - Phone:864-962-4140
Mailing Address - Fax:864-962-4142
Practice Address - Street 1:419 SE MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-2674
Practice Address - Country:US
Practice Address - Phone:864-962-4140
Practice Address - Fax:864-962-4142
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.6921 GD1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice