Provider Demographics
NPI:1831258706
Name:MARVIN, DANIEL TYLER (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:TYLER
Last Name:MARVIN
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 1:16992 73RD PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-2681
Mailing Address - Country:US
Mailing Address - Phone:763-425-3078
Mailing Address - Fax:
Practice Address - Street 1:4000 CENTRAL AVE NE
Practice Address - Street 2:SUITE 308
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-2968
Practice Address - Country:US
Practice Address - Phone:763-781-7475
Practice Address - Fax:763-781-0828
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND94731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice