Provider Demographics
NPI:1659357432
Name:TYLKA, THOMAS WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WILLIAM
Last Name:TYLKA
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 1:1400 STATE ROUTE F
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-2831
Mailing Address - Country:US
Mailing Address - Phone:573-774-6101
Mailing Address - Fax:573-774-6812
Practice Address - Street 1:1400 STATE ROUTE F
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2831
Practice Address - Country:US
Practice Address - Phone:573-774-6101
Practice Address - Fax:573-774-6812
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0188111223G0001X
MO20050370811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT135072040OtherDRIVER LICENSE