Provider Demographics
NPI:1376612887
Name:THOMAS L TYREE DDS INC
Entity Type:Organization
Organization Name:THOMAS L TYREE DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:TYREE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-453-6765
Mailing Address - Street 1:1702 OAK ST
Mailing Address - Street 2:
Mailing Address - City:KENOVA
Mailing Address - State:WV
Mailing Address - Zip Code:25530-1120
Mailing Address - Country:US
Mailing Address - Phone:304-453-6765
Mailing Address - Fax:304-453-1695
Practice Address - Street 1:1702 OAK ST
Practice Address - Street 2:
Practice Address - City:KENOVA
Practice Address - State:WV
Practice Address - Zip Code:25530-1120
Practice Address - Country:US
Practice Address - Phone:304-453-6765
Practice Address - Fax:304-453-1695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136238000Medicaid
WV0135603OtherDENTAL PROVIDER