Provider Demographics
NPI:1124304795
Name:RYAN P. MACRAE, LLC
Entity type:Organization
Organization Name:RYAN P. MACRAE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:MACRAE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-722-9255
Mailing Address - Street 1:635 OLD GREENVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-1219
Mailing Address - Country:US
Mailing Address - Phone:864-722-9255
Mailing Address - Fax:
Practice Address - Street 1:635 OLD GREENVILLE HWY
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1219
Practice Address - Country:US
Practice Address - Phone:864-722-9255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4031122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2X4031Medicaid
SC4031OtherLICENSE#
SCBM8836287OtherDEA#