Provider Demographics
NPI:1568699650
Name:SMITH, TYLER LOGAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:LOGAN
Last Name:SMITH
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 1:17725 WELCH PLZ STE B
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-1404
Mailing Address - Country:US
Mailing Address - Phone:402-932-9349
Mailing Address - Fax:
Practice Address - Street 1:17725 WELCH PLZ STE B
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-1404
Practice Address - Country:US
Practice Address - Phone:402-932-9349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6822122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist