Provider Demographics
NPI:1104207927
Name:ROBERT P. TYRRELL, D.D.S.
Entity Type:Organization
Organization Name:ROBERT P. TYRRELL, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-877-4715
Mailing Address - Street 1:PO BOX 228
Mailing Address - Street 2:
Mailing Address - City:KEMMERER
Mailing Address - State:WY
Mailing Address - Zip Code:83101-0228
Mailing Address - Country:US
Mailing Address - Phone:307-877-4715
Mailing Address - Fax:307-877-3475
Practice Address - Street 1:1702 ANTELOPE STREET
Practice Address - Street 2:
Practice Address - City:KEMMERER
Practice Address - State:WY
Practice Address - Zip Code:83101-3900
Practice Address - Country:US
Practice Address - Phone:307-877-4715
Practice Address - Fax:307-877-3475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116184900Medicaid