Provider Demographics
NPI:1922187020
Name:RYDER, MARK INGRAM (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:INGRAM
Last Name:RYDER
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 1:521 PARNASSUS AVE
Mailing Address - Street 2:ROOM C-628
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2206
Mailing Address - Country:US
Mailing Address - Phone:415-476-1699
Mailing Address - Fax:415-502-4990
Practice Address - Street 1:521 PARNASSUS AVE
Practice Address - Street 2:ROOM C-628
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2206
Practice Address - Country:US
Practice Address - Phone:415-476-1699
Practice Address - Fax:415-502-4990
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA514461223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA51446OtherCALIFORNIA DENTAL LICENCE