Provider Demographics
NPI:1811379530
Name:CICERO, RYAN JOSEPH (DMD)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:JOSEPH
Last Name:CICERO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34225 N 27TH DRIVE
Mailing Address - Street 2:BLDG 5 STE 241
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-6019
Mailing Address - Country:US
Mailing Address - Phone:623-439-2280
Mailing Address - Fax:
Practice Address - Street 1:34225 N 27TH DRIVE
Practice Address - Street 2:BLDG 5 STE 240
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085
Practice Address - Country:US
Practice Address - Phone:623-322-1538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009230122300000X
AZD92301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist