Healthcare Provider Details

I. General information

NPI: 1639564784
Provider Name (Legal Business Name): TYLER QUINN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2015
Last Update Date: 01/28/2026
Certification Date: 01/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 S STAPLEY DR STE 208
MESA AZ
85204-6659
US

IV. Provider business mailing address

1630 S STAPLEY DR STE 208
MESA AZ
85204-6659
US

V. Phone/Fax

Practice location:
  • Phone: 480-775-2656
  • Fax:
Mailing address:
  • Phone: 480-775-2656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401418531
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number1001094-15
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD012614
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: