Provider Demographics
NPI:1740756345
Name:GRACE TYLO LLC
Entity Type:Organization
Organization Name:GRACE TYLO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-563-3330
Mailing Address - Street 1:35 COLD SPRING RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-3160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 COLD SPRING RD STE 324
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-3163
Practice Address - Country:US
Practice Address - Phone:860-563-3330
Practice Address - Fax:860-563-3058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty