Provider Demographics
NPI:1255539375
Name:HUSSONG, RYAN DEAN (DDS)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DEAN
Last Name:HUSSONG
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 1:1010 S 3RD ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50226-1181
Mailing Address - Country:US
Mailing Address - Phone:515-984-6001
Mailing Address - Fax:515-984-6707
Practice Address - Street 1:1010 S 3RD ST STE 2A
Practice Address - Street 2:
Practice Address - City:POLK CITY
Practice Address - State:IA
Practice Address - Zip Code:50226-1181
Practice Address - Country:US
Practice Address - Phone:515-984-6001
Practice Address - Fax:515-984-6707
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA084911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0080200Medicaid