Provider Demographics
NPI:1912492364
Name:PHILLIPS, TYLER WAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:WAYNE
Last Name:PHILLIPS
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 1:13001 SIMSBURY TER
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-8429
Mailing Address - Country:US
Mailing Address - Phone:816-617-6447
Mailing Address - Fax:
Practice Address - Street 1:305 SW PINE ISLAND RD UNIT 1
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-2044
Practice Address - Country:US
Practice Address - Phone:855-623-6023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL235551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice