Healthcare Provider Details

I. General information

NPI: 1033484944
Provider Name (Legal Business Name): TYLER JAMES BANACHOWSKI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2012
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2223 SARNO RD
MELBOURNE FL
32935-3003
US

IV. Provider business mailing address

2223 SARNO RD
MELBOURNE FL
32935-3003
US

V. Phone/Fax

Practice location:
  • Phone: 321-425-2018
  • Fax:
Mailing address:
  • Phone: 321-425-2018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN24505
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN24505
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: