Provider Demographics
NPI:1801041512
Name:DICK, WILLIAM RYAN
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:RYAN
Last Name:DICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W 920 S TRLR 64
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-5805
Mailing Address - Country:US
Mailing Address - Phone:801-318-3216
Mailing Address - Fax:
Practice Address - Street 1:340 W 920 S TRLR 64
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-5805
Practice Address - Country:US
Practice Address - Phone:801-318-3216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7113263-1702390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program