Provider Demographics
NPI:1487059721
Name:GOERGEN, RYAN (DMD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:GOERGEN
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 1:3143 EVERGLADE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-3316
Mailing Address - Country:US
Mailing Address - Phone:630-291-0957
Mailing Address - Fax:
Practice Address - Street 1:4055 LINDELL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3201
Practice Address - Country:US
Practice Address - Phone:314-535-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140383551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice