Provider Demographics
NPI:1194803239
Name:JAMES A RYERSON DMD AND MARY LEIGH GILLESPIE DMD PC LLC
Entity type:Organization
Organization Name:JAMES A RYERSON DMD AND MARY LEIGH GILLESPIE DMD PC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:RYERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-381-2100
Mailing Address - Street 1:1013 E AVALON AVENUE
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661
Mailing Address - Country:US
Mailing Address - Phone:256-381-2100
Mailing Address - Fax:256-381-4844
Practice Address - Street 1:1013 E AVALON AVENUE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661
Practice Address - Country:US
Practice Address - Phone:256-381-2100
Practice Address - Fax:256-381-4844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2974122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
02347Medicare UPIN