Provider Demographics
NPI:1093557589
Name:GREEN, RYAN (DMD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:GREEN
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 1:482 N 20 W
Mailing Address - Street 2:
Mailing Address - City:VINEYARD
Mailing Address - State:UT
Mailing Address - Zip Code:84059-6546
Mailing Address - Country:US
Mailing Address - Phone:435-619-6025
Mailing Address - Fax:
Practice Address - Street 1:5455 W 11000 N STE 202
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-8802
Practice Address - Country:US
Practice Address - Phone:801-492-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13921187-99261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice