Provider Demographics
NPI:1962793174
Name:COLLETTA, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:COLLETTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:
Other - Last Name:COLLETTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26357 MCBEAN PKWY STE 255
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-5504
Mailing Address - Country:US
Mailing Address - Phone:661-255-1515
Mailing Address - Fax:661-255-1661
Practice Address - Street 1:26357 MCBEAN PKWY STE 255
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-5504
Practice Address - Country:US
Practice Address - Phone:661-255-1515
Practice Address - Fax:661-255-1661
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2015-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA644241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery