Provider Demographics
NPI:1861500621
Name:RYAN, MICHAEL JEROME (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JEROME
Last Name:RYAN
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 1:17027 SO HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2739
Mailing Address - Country:US
Mailing Address - Phone:708-429-7878
Mailing Address - Fax:708-429-7173
Practice Address - Street 1:17027 SO HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2739
Practice Address - Country:US
Practice Address - Phone:708-429-7878
Practice Address - Fax:708-429-7173
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist