Healthcare Provider Details

I. General information

NPI: 1013909985
Provider Name (Legal Business Name): KENNETH DALE TYLER D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/23/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

9097 E DESERT COVE AVE
SCOTTSDALE AZ
85260-6277
US

IV. Provider business mailing address

PO BOX 14123
SCOTTSDALE AZ
85267-4123
US

V. Phone/Fax

Practice location:
  • Phone: 480-860-1474
  • Fax:
Mailing address:
  • Phone: 480-860-1474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4456
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: