Provider Demographics
NPI:1437568169
Name:WILSON, TYLER J (DMD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 CHEVY WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4127
Mailing Address - Country:US
Mailing Address - Phone:541-690-3555
Mailing Address - Fax:541-842-2212
Practice Address - Street 1:4940 HAMRICK RD
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-3072
Practice Address - Country:US
Practice Address - Phone:541-690-3600
Practice Address - Fax:541-664-3735
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist