Provider Demographics
NPI:1568718146
Name:JOHANSEN, TYLER RUSSELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:RUSSELL
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 CEDAR CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29906-3000
Mailing Address - Country:US
Mailing Address - Phone:530-276-3389
Mailing Address - Fax:
Practice Address - Street 1:674 BLVD DE FRANCE
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29905
Practice Address - Country:US
Practice Address - Phone:843-228-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS039183122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist