Provider Demographics
NPI:1861629941
Name:PERRERO, TYSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:
Last Name:PERRERO
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 1:2105 WEBER AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2110
Mailing Address - Country:US
Mailing Address - Phone:502-473-2011
Mailing Address - Fax:502-473-2013
Practice Address - Street 1:2105 WEBER AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-2110
Practice Address - Country:US
Practice Address - Phone:502-473-2011
Practice Address - Fax:502-473-2013
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY90541223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100178410Medicaid