Provider Demographics
NPI:1497840532
Name:PITTMAN, TYLER LANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:LANE
Last Name:PITTMAN
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 1:1740 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-3736
Mailing Address - Country:US
Mailing Address - Phone:276-466-2028
Mailing Address - Fax:276-466-1629
Practice Address - Street 1:1740 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-3736
Practice Address - Country:US
Practice Address - Phone:276-466-2028
Practice Address - Fax:276-466-1629
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014102221223G0001X
TNDS00000077761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1300698OtherUNITED CONCORDIA
TN3158606OtherBCBS OF TN
VA061550OtherBCBS OF VA