Healthcare Provider Details

I. General information

NPI: 1740952472
Provider Name (Legal Business Name): TYLER KAYLE LONGFELLOW DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 09/30/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S BINKLEY ST STE A
SOLDOTNA AK
99669-8038
US

IV. Provider business mailing address

288 GERANIUM RD
SOLDOTNA AK
99669-7968
US

V. Phone/Fax

Practice location:
  • Phone: 907-262-8834
  • Fax:
Mailing address:
  • Phone: 801-791-1760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number182292
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: