1841346632 NPI number — DR. RYAN LEE DONNELLY DMD

Table of content: DR. RYAN LEE DONNELLY DMD (NPI 1841346632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841346632 NPI number — DR. RYAN LEE DONNELLY DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DONNELLY
Provider First Name:
RYAN
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DONNELY
Provider Other First Name:
RYAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1841346632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12100 SE STEVENS COURT, SUITE 101
Provider Second Line Business Mailing Address:
RYAN L. DONNELLY CO MT. SCOTT FAMILY DENTAL
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-353-9000
Provider Business Mailing Address Fax Number:
503-786-1873

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12100 SE STEVENS COURT, SUITE 101
Provider Second Line Business Practice Location Address:
RYAN L DONNELLY
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-353-9000
Provider Business Practice Location Address Fax Number:
503-786-1873
Provider Enumeration Date:
01/26/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D8599 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)