Provider Demographics
NPI:1255991972
Name:PARKER, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PARKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-3313
Mailing Address - Country:US
Mailing Address - Phone:904-249-3104
Mailing Address - Fax:904-249-3109
Practice Address - Street 1:1023 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-3313
Practice Address - Country:US
Practice Address - Phone:904-249-3104
Practice Address - Fax:904-249-3109
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN242681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice