Provider Demographics
NPI:1275984205
Name:TYRA, ELWIRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELWIRA
Middle Name:
Last Name:TYRA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 TAYLOR ST STE 4
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-1332
Mailing Address - Country:US
Mailing Address - Phone:413-781-7645
Mailing Address - Fax:
Practice Address - Street 1:41 TAYLOR ST STE 4
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1332
Practice Address - Country:US
Practice Address - Phone:413-781-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18588731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice