Provider Demographics
NPI:1215128350
Name:MOFFETT, RYAN SEAN (DMD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:SEAN
Last Name:MOFFETT
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 1:1463 MAYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-3418
Mailing Address - Country:US
Mailing Address - Phone:609-420-3643
Mailing Address - Fax:
Practice Address - Street 1:409 DUNLAP ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4201
Practice Address - Country:US
Practice Address - Phone:609-420-3643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12882122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist