Provider Demographics
NPI:1174055453
Name:SHAFFER, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14904-2709
Mailing Address - Country:US
Mailing Address - Phone:607-734-9503
Mailing Address - Fax:866-489-7553
Practice Address - Street 1:1118 CHARLES ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14904-2709
Practice Address - Country:US
Practice Address - Phone:607-734-9503
Practice Address - Fax:866-489-7553
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029041124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist