Provider Demographics
NPI:1932529526
Name:SMITH, TYLER (DMD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
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 1:161 E 88TH ST
Mailing Address - Street 2:APT 5D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-2245
Mailing Address - Country:US
Mailing Address - Phone:763-443-5212
Mailing Address - Fax:
Practice Address - Street 1:1737 YORK AVE
Practice Address - Street 2:1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-6841
Practice Address - Country:US
Practice Address - Phone:212-534-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND135881223G0001X
NY058312122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice