Healthcare Provider Details

I. General information

NPI: 1477228468
Provider Name (Legal Business Name): TYLER MOYLE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 W BRIGGSMORE AVE
MODESTO CA
95350-3767
US

IV. Provider business mailing address

7013 DAKOTA DR
WEST DES MOINES IA
50266-2410
US

V. Phone/Fax

Practice location:
  • Phone: 515-975-7815
  • Fax:
Mailing address:
  • Phone: 515-975-7815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number106832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: