Provider Demographics
NPI:1073133393
Name:ANTONELLI, TYLER (DDS)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:ANTONELLI
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 1:4175 S ALAMO AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS-MONTHAN AFB
Mailing Address - State:AZ
Mailing Address - Zip Code:85707
Mailing Address - Country:US
Mailing Address - Phone:910-619-6720
Mailing Address - Fax:
Practice Address - Street 1:4175 S ALAMO AVE
Practice Address - Street 2:
Practice Address - City:DAVIS-MONTHAN AFB
Practice Address - State:AZ
Practice Address - Zip Code:85707
Practice Address - Country:US
Practice Address - Phone:910-619-6720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11977122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist