Provider Demographics
NPI:1811067432
Name:SHAW, TYLER C (DDS)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:C
Last Name:SHAW
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 1:1245 CAPITOL ST STE 111-S
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-2893
Mailing Address - Country:US
Mailing Address - Phone:801-394-1289
Mailing Address - Fax:801-394-8397
Practice Address - Street 1:1245 CAPITOL ST STE 111-S
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-2893
Practice Address - Country:US
Practice Address - Phone:801-394-1289
Practice Address - Fax:801-394-8397
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3085121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice