Provider Demographics
NPI:1679922843
Name:TYNER, CANAAN BURKE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CANAAN
Middle Name:BURKE
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 1:256 BROADWAY APT 203
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-3237
Mailing Address - Country:US
Mailing Address - Phone:518-683-0756
Mailing Address - Fax:
Practice Address - Street 1:500 FEDERAL ST STE 600
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2832
Practice Address - Country:US
Practice Address - Phone:518-274-4322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0607091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty