Provider Demographics
NPI:1598050122
Name:PICKETT, TYLER JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:JOHN
Last Name:PICKETT
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 1:6644 CABIN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-9220
Mailing Address - Country:US
Mailing Address - Phone:402-699-9036
Mailing Address - Fax:
Practice Address - Street 1:5198 N NEVADA AVE STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-8649
Practice Address - Country:US
Practice Address - Phone:719-634-8884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-11
Last Update Date:2011-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice