Provider Demographics
NPI:1437564085
Name:DEROUIN, TYLER ROSS
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:ROSS
Last Name:DEROUIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3411
Mailing Address - Country:US
Mailing Address - Phone:218-847-2624
Mailing Address - Fax:218-847-5792
Practice Address - Street 1:1136 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3411
Practice Address - Country:US
Practice Address - Phone:218-847-2624
Practice Address - Fax:218-847-5792
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND134171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice