Provider Demographics
NPI:1114195112
Name:BROSS, TYSON GARY (DMD, PHD)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:GARY
Last Name:BROSS
Suffix:
Gender:M
Credentials:DMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 LUBRANO DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7564
Mailing Address - Country:US
Mailing Address - Phone:410-224-0018
Mailing Address - Fax:410-224-4214
Practice Address - Street 1:129 LUBRANO DR
Practice Address - Street 2:SUITE 300
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7564
Practice Address - Country:US
Practice Address - Phone:410-224-0018
Practice Address - Fax:410-224-4214
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS036891122300000X
MD140241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist