Provider Demographics
NPI:1144874132
Name:RAE, TYLER BRANTLEY (DMD)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:BRANTLEY
Last Name:RAE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 TROUTDALE LN
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-6465
Mailing Address - Country:US
Mailing Address - Phone:864-704-7455
Mailing Address - Fax:
Practice Address - Street 1:8024 AUGUSTA RD UNIT G
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:SC
Practice Address - Zip Code:29673-6595
Practice Address - Country:US
Practice Address - Phone:864-277-9343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC94611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice