Provider Demographics
NPI:1225697196
Name:TYER, STEPHEN (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:TYER
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 1:275 KAYLA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4257
Mailing Address - Country:US
Mailing Address - Phone:318-865-0530
Mailing Address - Fax:
Practice Address - Street 1:275 KAYLA ST STE 100
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4257
Practice Address - Country:US
Practice Address - Phone:318-865-0530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA69851223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health