Provider Demographics
NPI:1821703018
Name:STANWORTH, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:STANWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 MERCHANTS ROW STE 104
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-4476
Mailing Address - Country:US
Mailing Address - Phone:802-497-6310
Mailing Address - Fax:
Practice Address - Street 1:62 MERCHANTS ROW STE 104
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-4476
Practice Address - Country:US
Practice Address - Phone:802-497-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT016.01341801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program