Healthcare Provider Details

I. General information

NPI: 1770817389
Provider Name (Legal Business Name): EMILY WELDON TYLER D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 06/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 US HIGHWAY 1 S SUITE B
ST AUGUSTINE FL
32086-6100
US

IV. Provider business mailing address

2510 US HIGHWAY 1 S SUITE B
ST AUGUSTINE FL
32086-6100
US

V. Phone/Fax

Practice location:
  • Phone: 904-217-7012
  • Fax: 904-217-7924
Mailing address:
  • Phone: 904-217-7012
  • Fax: 904-217-7924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN18665
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: