Healthcare Provider Details

I. General information

NPI: 1902336555
Provider Name (Legal Business Name): TYLER J WYLDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12222 IL-47
HUNTLEY IL
60142
US

IV. Provider business mailing address

12222 IL-47
HUNTLEY IL
60142
US

V. Phone/Fax

Practice location:
  • Phone: 224-654-6920
  • Fax: 224-654-6052
Mailing address:
  • Phone: 224-654-6920
  • Fax: 224-654-6052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019031157
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: