Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 62953 | CA |
NPI | 1003245945 |
---|---|
Provider Name | Ryan Malan |
First Address | Fort Sill, OK 73503 |
Second Address | Fort Sill, OK 73503 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2013 |
Last Update Date | 01/11/2013 |