MEDICARE: DR. JOHN T TYSON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN9494	FL

General Provider Information

NPI Number	:	1487699534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN T TYSON DMD

Provider Business Mailing Address
First Line	:	19874 WILKINSON LEAS RD
Second Line	:
City	:	TEQUESTA
State	:	FL
Zip	:	33469-2178
Country	:	US
Telephone Number	:	561-746-7702
Fax Number	:	561-746-6355

Provider Business Practice Location Address
First Line	:	2614 SE WILLOUGHBY BLVD
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34994-4700
Country	:	US
Telephone Number	:	772-283-8555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	10/24/2008

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