Provider Demographics
NPI:1780606590
Name:RYAN, VICKY RAE (DDS)
Entity type:Individual
Prefix:DR
First Name:VICKY
Middle Name:RAE
Last Name:RYAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:VICKY
Other - Middle Name:RYAN
Other - Last Name:HASKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:6881 WOODCHUCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-9746
Mailing Address - Country:US
Mailing Address - Phone:315-445-7998
Mailing Address - Fax:
Practice Address - Street 1:50 PRESIDENTIAL PLZ
Practice Address - Street 2:SUITE 105
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2229
Practice Address - Country:US
Practice Address - Phone:315-472-1186
Practice Address - Fax:315-472-7303
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0444171223G0001X
CADY316931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice