Provider Demographics
NPI:1265686836
Name:LANDERS, TYRONE ANTONIO (DMD)
Entity type:Individual
Prefix:DR
First Name:TYRONE
Middle Name:ANTONIO
Last Name:LANDERS
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 1:3654 RICHWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28081-6704
Mailing Address - Country:US
Mailing Address - Phone:980-939-3017
Mailing Address - Fax:704-548-2767
Practice Address - Street 1:8525 PIT STOP CT NW STE A&B
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-8337
Practice Address - Country:US
Practice Address - Phone:704-548-2700
Practice Address - Fax:704-548-2767
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8895122300000X, 1223G0001X
MS3487-081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5915451Medicaid