Provider Demographics
NPI:1205451598
Name:WOOD, TYSEN (DMD)
Entity type:Individual
Prefix:DR
First Name:TYSEN
Middle Name:
Last Name:WOOD
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3877 E AMITY RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8380
Mailing Address - Country:US
Mailing Address - Phone:208-900-4669
Mailing Address - Fax:
Practice Address - Street 1:3877 E AMITY RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8380
Practice Address - Country:US
Practice Address - Phone:208-900-4669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002293-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice