Provider Demographics
NPI:1780714915
Name:SMITH, TYLER J (DMD)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:SMITH
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 1:2200 E WARM SPRINGS AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-8405
Mailing Address - Country:US
Mailing Address - Phone:208-343-2000
Mailing Address - Fax:208-392-1384
Practice Address - Street 1:2200 E WARM SPRINGS AVE STE 108
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-830-4438
Practice Address - Fax:208-392-1384
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-38981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010157744OtherBLUESHIELD OF IDAHO #
IDCS11082OtherIDAHO CONTROLLED SUBSTANC
IDD-3898OtherIDAHO DENTISTRY LICENSE
IDD-3898OtherIDAHO DENTISTRY LICENSE