Provider Demographics
NPI:1720311442
Name:WOMACK, RYAN DAVID (MD, DDS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:WOMACK
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 YAUGER WAY SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:OLYMIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502
Mailing Address - Country:US
Mailing Address - Phone:360-754-9444
Mailing Address - Fax:
Practice Address - Street 1:400 YAUGER WAY SW
Practice Address - Street 2:SUITE A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8139
Practice Address - Country:US
Practice Address - Phone:360-754-9444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD.6028171881223S0112X
WADE.602806471223S0112X
TXM6467204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery