Provider Demographics
NPI:1689765315
Name:TINER, RICHARD TRAVIS (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:TRAVIS
Last Name:TINER
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 BROADWAY BLVD
Mailing Address - Street 2:SUTIE 201
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75041-3764
Mailing Address - Country:US
Mailing Address - Phone:972-271-6528
Mailing Address - Fax:972-271-6529
Practice Address - Street 1:2910 BROADWAY BLVD
Practice Address - Street 2:SUTIE 201
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-3764
Practice Address - Country:US
Practice Address - Phone:972-271-6528
Practice Address - Fax:972-271-6529
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD108591223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD10859Medicare ID - Type Unspecified
TXT16301Medicare UPIN