Provider Demographics
NPI:1821795634
Name:GALLEGOS, RYAN KADE (DDS)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:KADE
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:1275 N TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1176
Practice Address - Country:US
Practice Address - Phone:844-853-8937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.027414122300000X, 1223P0221X
MO20250125081223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0051210Medicaid