Provider Demographics
NPI:1992880132
Name:HILLAM, RYAN DAVID (DDS)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:HILLAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 N.WHITLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619
Mailing Address - Country:US
Mailing Address - Phone:208-452-4808
Mailing Address - Fax:208-452-6617
Practice Address - Street 1:1820 N.WHITLEY DRIVE
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619
Practice Address - Country:US
Practice Address - Phone:208-452-4808
Practice Address - Fax:208-452-6617
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist