Provider Demographics
NPI:1609268861
Name:OWENS, TYLER (DMD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:OWENS
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 1:400 RIVERWALK TER STE 250
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5619
Mailing Address - Country:US
Mailing Address - Phone:918-998-0996
Mailing Address - Fax:918-235-9079
Practice Address - Street 1:3100 E ZORA ST
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-9770
Practice Address - Country:US
Practice Address - Phone:417-228-8286
Practice Address - Fax:512-442-6074
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6969122300000X
KS615201223P0221X
MO20190052721223P0221X
OK1061223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200715230AMedicaid
MO830082149Medicaid
KS201253250AMedicaid