Provider Demographics
NPI:1073202198
Name:MERRITT, RYAN ANTHONY (DMD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:ANTHONY
Last Name:MERRITT
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 1:5445 TELEGRAPH RD STE 111
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-3500
Mailing Address - Country:US
Mailing Address - Phone:314-892-2120
Mailing Address - Fax:
Practice Address - Street 1:5445 TELEGRAPH RD STE 111
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-3500
Practice Address - Country:US
Practice Address - Phone:314-892-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO20240228891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program