Provider Demographics
NPI:1487632949
Name:ROETHLISBERGER, TYSON J (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:J
Last Name:ROETHLISBERGER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 N MACOMB ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2982
Mailing Address - Country:US
Mailing Address - Phone:734-241-6710
Mailing Address - Fax:734-241-6710
Practice Address - Street 1:721 N MACOMB ST
Practice Address - Street 2:SUITE 3
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-2982
Practice Address - Country:US
Practice Address - Phone:734-241-6710
Practice Address - Fax:734-241-6710
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010158341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice