Healthcare Provider Details

I. General information

NPI: 1750887410
Provider Name (Legal Business Name): TYLER DEANDA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204-4597
US

IV. Provider business mailing address

301 W 6TH AVE
DENVER CO
80204-5182
US

V. Phone/Fax

Practice location:
  • Phone: 303-602-8200
  • Fax: 303-602-4560
Mailing address:
  • Phone: 630-687-0114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00204069
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: