Provider Demographics
NPI:1194295485
Name:COE, RYAN WESLEY (RDH)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:WESLEY
Last Name:COE
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BAYHARBOR WAY
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2586
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6090 REDWOOD BLVD
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-4569
Practice Address - Country:US
Practice Address - Phone:415-448-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31368124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist