Provider Demographics
NPI:1750942462
Name:SMITH, TYLER (DDS)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:SMITH
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 1:5451 BRECKENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431
Mailing Address - Country:US
Mailing Address - Phone:248-842-5278
Mailing Address - Fax:
Practice Address - Street 1:3988 N OCEANA DR
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-8358
Practice Address - Country:US
Practice Address - Phone:231-873-9340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010232131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice