Provider Demographics
NPI:1912134024
Name:DIQUATTRO, RYAN L
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:L
Last Name:DIQUATTRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 S MEADOW ST
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:704 SOUTH MEADOW STREET
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541
Practice Address - Country:US
Practice Address - Phone:928-474-5231
Practice Address - Fax:928-474-5231
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ77581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice