Provider Demographics
NPI:1699039339
Name:ROULSTON, TYSON HEATH (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:HEATH
Last Name:ROULSTON
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 1:19434 W 105TH ST S
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-8055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1226 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:DRUMRIGHT
Practice Address - State:OK
Practice Address - Zip Code:74030-5826
Practice Address - Country:US
Practice Address - Phone:918-352-3312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK64071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice