Provider Demographics
NPI:1518205202
Name:PRESTWICH, TYLER CARL (DDS, PHD, MS)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:CARL
Last Name:PRESTWICH
Suffix:
Gender:M
Credentials:DDS, PHD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1015 S BROADWAY STE 17
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4667
Mailing Address - Country:US
Mailing Address - Phone:701-852-2646
Mailing Address - Fax:701-839-1019
Practice Address - Street 1:1015 S BROADWAY STE 17
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4667
Practice Address - Country:US
Practice Address - Phone:701-852-2646
Practice Address - Fax:701-839-1019
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-30
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDT22711223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics