Provider Demographics
NPI:1982175378
Name:DEWALD, TYE
Entity Type:Individual
Prefix:
First Name:TYE
Middle Name:
Last Name:DEWALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CARLEIGH
Other - Middle Name:
Other - Last Name:DEWALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21356 HUBBARD CUTOFF RD NE UNIT 9
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OR
Mailing Address - Zip Code:97002-8401
Mailing Address - Country:US
Mailing Address - Phone:503-592-3204
Mailing Address - Fax:
Practice Address - Street 1:11073 SE MAIN ST
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7645
Practice Address - Country:US
Practice Address - Phone:503-592-3204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist