Provider Demographics
NPI:1508126491
Name:TYLER FORDHAM DDS PLLC
Entity Type:Organization
Organization Name:TYLER FORDHAM DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:FORDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-349-4001
Mailing Address - Street 1:82 MASONIC HALL RD
Mailing Address - Street 2:
Mailing Address - City:PORT HADLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98339-9567
Mailing Address - Country:US
Mailing Address - Phone:360-349-4001
Mailing Address - Fax:
Practice Address - Street 1:1233 W SIMS WAY
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-3057
Practice Address - Country:US
Practice Address - Phone:360-349-4001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602127231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty