Provider Demographics
NPI:1578040374
Name:BREKKE, TYLOR DANIEL (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:TYLOR
Middle Name:DANIEL
Last Name:BREKKE
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 SW MOODY AVE, SD-ORTHO
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5042
Mailing Address - Country:US
Mailing Address - Phone:504-459-7940
Mailing Address - Fax:
Practice Address - Street 1:536 SE OAK ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4118
Practice Address - Country:US
Practice Address - Phone:503-648-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR390200000X
ORD112291223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty