Provider Demographics
NPI:1942321518
Name:RYSER, MARK RALPH (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RALPH
Last Name:RYSER
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6287 S REDWOOD RD STE 103
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6653
Mailing Address - Country:US
Mailing Address - Phone:801-261-2444
Mailing Address - Fax:
Practice Address - Street 1:6287 S REDWOOD RD STE 103
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-6653
Practice Address - Country:US
Practice Address - Phone:801-261-2444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6540390-99241223S0112X
UT6540390-1205204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1057428Medicaid