Provider Demographics
NPI:1396314365
Name:CHANCELLOR, TYLER (DDS)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:CHANCELLOR
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 1:716 WILLIAMSBURG BLVD
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5538
Mailing Address - Country:US
Mailing Address - Phone:303-915-4694
Mailing Address - Fax:
Practice Address - Street 1:4016 LEMAY FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1858
Practice Address - Country:US
Practice Address - Phone:303-305-4062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002047881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice