Provider Demographics
NPI:1457786741
Name:BULLEN, RYAN NEWELL (DMD, DHSC)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:NEWELL
Last Name:BULLEN
Suffix:
Gender:M
Credentials:DMD, DHSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 W BELLO VISTA PLZ
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-2975
Mailing Address - Country:US
Mailing Address - Phone:801-787-6883
Mailing Address - Fax:
Practice Address - Street 1:1845 MCCULLOCH BLVD N STE A1
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5722
Practice Address - Country:US
Practice Address - Phone:928-855-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86931223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics