Provider Demographics
NPI:1578738068
Name:TYLER SHOEMAKER DMD PC
Entity Type:Organization
Organization Name:TYLER SHOEMAKER DMD PC
Other - Org Name:PRIEST RIVER DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-448-2694
Mailing Address - Street 1:314 E ALBENI HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PRIEST RIVER
Mailing Address - State:ID
Mailing Address - Zip Code:83856-9207
Mailing Address - Country:US
Mailing Address - Phone:208-448-2694
Mailing Address - Fax:208-448-1703
Practice Address - Street 1:314 E ALBENI HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856-9207
Practice Address - Country:US
Practice Address - Phone:208-448-2694
Practice Address - Fax:208-448-1703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD41281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty