Provider Demographics
NPI:1588002430
Name:KOIVISTO, TYLER J (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:J
Last Name:KOIVISTO
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 1:1430 HIGHWAY 96
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110
Mailing Address - Country:US
Mailing Address - Phone:651-426-9502
Mailing Address - Fax:651-653-2158
Practice Address - Street 1:1430 HIGHWAY 96
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110
Practice Address - Country:US
Practice Address - Phone:651-426-9502
Practice Address - Fax:651-653-2158
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13236122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist