Provider Demographics
NPI:1790096154
Name:DAVIS, TYLER (DMD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 S SAN MATEO DR STE 160
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3859
Mailing Address - Country:US
Mailing Address - Phone:650-375-8300
Mailing Address - Fax:
Practice Address - Street 1:50 S SAN MATEO DR STE 160
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3859
Practice Address - Country:US
Practice Address - Phone:650-375-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855461122300000X
CADDS613911223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist