Provider Demographics
NPI:1952505984
Name:TEEPLES, TYSON (DMD, MD)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:TEEPLES
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 N YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7806
Mailing Address - Country:US
Mailing Address - Phone:509-783-7600
Mailing Address - Fax:
Practice Address - Street 1:512 N YOUNG ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7806
Practice Address - Country:US
Practice Address - Phone:509-783-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MND12473204E00000X
WADE602669721223S0112X
ORD97011223S0112X, 204E00000X
WA60266972204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN366965000Medicaid
MN850000123Medicare PIN
MN190000910Medicare PIN