Provider Demographics
NPI:1922621655
Name:HUMPHREYS, MARK RYAN (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RYAN
Last Name:HUMPHREYS
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 1:430 WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:OH
Mailing Address - Zip Code:45380-1356
Mailing Address - Country:US
Mailing Address - Phone:937-638-3852
Mailing Address - Fax:
Practice Address - Street 1:1523 N MARKET ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-9767
Practice Address - Country:US
Practice Address - Phone:937-335-4630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0261571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice