Provider Demographics
NPI:1053490961
Name:DO, DUTRAN TYLER (MD, DMD)
Entity Type:Individual
Prefix:DR
First Name:DUTRAN
Middle Name:TYLER
Last Name:DO
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12401 WILSHIRE BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1015
Mailing Address - Country:US
Mailing Address - Phone:203-200-7280
Mailing Address - Fax:
Practice Address - Street 1:12401 WILSHIRE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1015
Practice Address - Country:US
Practice Address - Phone:203-200-7280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2022-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052760122300000X
CA64626122300000X
CT049194204E00000X
NY257471204E00000X
CAC139636204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist