Provider Demographics
NPI:1336781673
Name:SYDNOR, TIARRA NICOLE
Entity Type:Individual
Prefix:
First Name:TIARRA
Middle Name:NICOLE
Last Name:SYDNOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 S GETTY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1207
Mailing Address - Country:US
Mailing Address - Phone:231-737-1805
Mailing Address - Fax:
Practice Address - Street 1:2201 S GETTY ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:49444-1207
Practice Address - Country:US
Practice Address - Phone:231-737-1805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902019143124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist