Provider Demographics
NPI:1023121795
Name:KOWALCZYK, RYAN M (DDS)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:M
Last Name:KOWALCZYK
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 1:1625 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5155
Mailing Address - Country:US
Mailing Address - Phone:208-890-1247
Mailing Address - Fax:208-549-5988
Practice Address - Street 1:1625 W BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5155
Practice Address - Country:US
Practice Address - Phone:208-342-5444
Practice Address - Fax:208-342-2076
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-36891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6P481OtherBLUE CROSS OF IDAHO