Provider Demographics
NPI:1750802997
Name:HOLBROOK, RYAN MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MICHAEL
Last Name:HOLBROOK
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 1:422 LINCOLN TERRACE CT
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3981
Mailing Address - Country:US
Mailing Address - Phone:314-409-9981
Mailing Address - Fax:
Practice Address - Street 1:640 W KARSCH BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3342
Practice Address - Country:US
Practice Address - Phone:573-218-0346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170172771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice