Provider Demographics
NPI:1851850705
Name:RYSENGA, WILLIAM CHARLES (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:CHARLES
Last Name:RYSENGA
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 1:1230 TAMARACK ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-6505
Mailing Address - Country:US
Mailing Address - Phone:503-446-9823
Mailing Address - Fax:
Practice Address - Street 1:VINCENT AVENUE
Practice Address - Street 2:BLDG. #626
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368
Practice Address - Country:US
Practice Address - Phone:315-630-4817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11084122300000X, 1223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program