Provider Demographics
NPI:1336659721
Name:TYSON BROSS DMD PHD LLC
Entity Type:Organization
Organization Name:TYSON BROSS DMD PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:BROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PHD
Authorized Official - Phone:443-373-1634
Mailing Address - Street 1:101 EARECKSON LN
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21666-3037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:129 LUBRANO DR STE 300
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7568
Practice Address - Country:US
Practice Address - Phone:410-224-0018
Practice Address - Fax:410-224-4214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD140241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty