Provider Demographics
NPI:1942604533
Name:RYAN H WILSON DDS LLC
Entity Type:Organization
Organization Name:RYAN H WILSON DDS LLC
Other - Org Name:CANYON DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:HASTIIN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-278-7007
Mailing Address - Street 1:4760 N BUTLER AVE STE D
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-0816
Mailing Address - Country:US
Mailing Address - Phone:505-278-7007
Mailing Address - Fax:505-325-0817
Practice Address - Street 1:4760 N BUTLER AVE STE D
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-0816
Practice Address - Country:US
Practice Address - Phone:505-278-7007
Practice Address - Fax:505-325-0817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3162122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty