Provider Demographics
NPI:1922677632
Name:BARE, TYLER A (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:A
Last Name:BARE
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 1:203 E BROADWAY ST. PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:BOLIVER
Mailing Address - State:MO
Mailing Address - Zip Code:65613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 E BROADWAY ST. # 125
Practice Address - Street 2:
Practice Address - City:BOLIVER
Practice Address - State:MO
Practice Address - Zip Code:65613
Practice Address - Country:US
Practice Address - Phone:417-328-6334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210195711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice