Healthcare Provider Details

I. General information

NPI: 1487141552
Provider Name (Legal Business Name): TYLER W. JURY DMD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2018
Last Update Date: 04/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 PENDLETON RD
PENDLETON KY
40055-7721
US

IV. Provider business mailing address

1910 DEERWOOD AVE
LOUISVILLE KY
40205-1204
US

V. Phone/Fax

Practice location:
  • Phone: 502-743-9190
  • Fax:
Mailing address:
  • Phone: 502-649-8773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TYLER JURY
Title or Position: OWNER
Credential: DMD
Phone: 502-649-8773