Provider Demographics
NPI:1629323886
Name:MACK, TYLER RYAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:RYAN
Last Name:MACK
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 1:510 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-3910
Mailing Address - Country:US
Mailing Address - Phone:503-472-3147
Mailing Address - Fax:503-435-1451
Practice Address - Street 1:510 E 8TH ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-3910
Practice Address - Country:US
Practice Address - Phone:503-472-3147
Practice Address - Fax:503-435-1451
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD97401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice