Provider Demographics
NPI:1295116655
Name:VICK, RYAN EDWARD (DDS)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:EDWARD
Last Name:VICK
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 1:3011 CENTRE OAK WAY STE 102
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-6301
Mailing Address - Country:US
Mailing Address - Phone:901-701-7500
Mailing Address - Fax:
Practice Address - Street 1:3011 CENTRE OAK WAY STE 102
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-6301
Practice Address - Country:US
Practice Address - Phone:901-701-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN100761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice