Provider Demographics
NPI:1740322049
Name:RYAN, MARK T (DMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:RYAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 SAVIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4936
Mailing Address - Country:US
Mailing Address - Phone:203-933-7095
Mailing Address - Fax:203-937-5766
Practice Address - Street 1:622 SAVIN AVENUE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4936
Practice Address - Country:US
Practice Address - Phone:203-933-7095
Practice Address - Fax:203-937-5766
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008359122300000X
CT05006124Q00000X
CT005913124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered124Q00000XDental ProvidersDental Hygienist