Basic Information
| Provider Information | |||||||||
| NPI: | 1417382011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMILEY | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195768150 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 1407 W 84TH AVE UNIT B8 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802604753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202144746 | ||||||||
| FaxNumber: | 7202144745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2013 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DD3883 | NM | N | Dental Providers | Dentist | General Practice | 1223G0001X | 61451 | KS | N | Dental Providers | Dentist | General Practice | 1223G0001X | DEN.00202077 | CO | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 201206420A | 05 | KS | MEDICAID | 82004579 | 05 | CO | MEDICAID | 25959239 | 05 | NM | MEDICAID |