Provider Demographics
NPI:1619331634
Name:TYLER PERIODONTICS, PLLC
Entity Type:Organization
Organization Name:TYLER PERIODONTICS, PLLC
Other - Org Name:JOHN E. ADCOCK DDS MS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-581-2900
Mailing Address - Street 1:3805 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-9421
Mailing Address - Country:US
Mailing Address - Phone:903-581-2900
Mailing Address - Fax:903-509-0160
Practice Address - Street 1:3805 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9421
Practice Address - Country:US
Practice Address - Phone:903-581-2900
Practice Address - Fax:903-509-0160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX307011223P0300X
TX109111223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty