Provider Demographics
NPI:1578307435
Name:VAN RYN, NATHANIEL (DMD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:
Last Name:VAN RYN
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 1:16003 MORRISON RD
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-9561
Mailing Address - Country:US
Mailing Address - Phone:209-765-2017
Mailing Address - Fax:
Practice Address - Street 1:15680 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2221
Practice Address - Country:US
Practice Address - Phone:262-373-0344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001605-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist