Provider Demographics
NPI:1740952472
Name:LONGFELLOW, TYLER KAYLE (DMD)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:KAYLE
Last Name:LONGFELLOW
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 1:288 GERANIUM RD
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7968
Mailing Address - Country:US
Mailing Address - Phone:801-791-1760
Mailing Address - Fax:
Practice Address - Street 1:104 S BINKLEY ST STE A
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8038
Practice Address - Country:US
Practice Address - Phone:907-262-8834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1822921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice