Provider Demographics
NPI:1245451749
Name:RADER, RYAN LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:LEE
Last Name:RADER
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 1:1341 ROBERTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-3420
Mailing Address - Country:US
Mailing Address - Phone:618-558-5272
Mailing Address - Fax:
Practice Address - Street 1:11709 OLD BALLAS RD
Practice Address - Street 2:SUITE 206
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7029
Practice Address - Country:US
Practice Address - Phone:314-567-3760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060162361223P0300X
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0300XDental ProvidersDentistPeriodontics
Not Answered122300000XDental ProvidersDentist