Provider Demographics
NPI:1447617873
Name:TYSON, DENISE CAROL (DOM, LAC)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:CAROL
Last Name:TYSON
Suffix:
Gender:F
Credentials:DOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 BRANDERMILL BLVD
Mailing Address - Street 2:STE 301
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1604
Mailing Address - Country:US
Mailing Address - Phone:410-774-0800
Mailing Address - Fax:
Practice Address - Street 1:2401 BRANDERMILL BLVD
Practice Address - Street 2:STE 301
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1604
Practice Address - Country:US
Practice Address - Phone:410-774-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01974171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist