Provider Demographics
NPI:1669462776
Name:TYNER, MICHAEL A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:TYNER
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 1:10420 QUEENS BLVD
Mailing Address - Street 2:STE 1G
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3629
Mailing Address - Country:US
Mailing Address - Phone:718-896-0505
Mailing Address - Fax:718-897-6444
Practice Address - Street 1:10420 QUEENS BLVD
Practice Address - Street 2:STE 1G
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3629
Practice Address - Country:US
Practice Address - Phone:718-896-0505
Practice Address - Fax:718-897-6444
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY386381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice