Provider Demographics
NPI:1396196481
Name:DR. MATT TYSON, DDS, PC
Entity Type:Organization
Organization Name:DR. MATT TYSON, DDS, PC
Other - Org Name:TYSON FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:A
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDD
Authorized Official - Phone:214-675-9116
Mailing Address - Street 1:8113 CAMP BOWIE WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76116-6314
Mailing Address - Country:US
Mailing Address - Phone:817-560-9300
Mailing Address - Fax:817-560-9303
Practice Address - Street 1:8113 CAMP BOWIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76116-6314
Practice Address - Country:US
Practice Address - Phone:817-560-9300
Practice Address - Fax:817-560-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24696122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1578799250Medicaid