Healthcare Provider Details

I. General information

NPI: 1649630609
Provider Name (Legal Business Name): KYLE BURTON TYLER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 BIELENBERG DRIVE SUITE 160
WOODBURY MN
55125
US

IV. Provider business mailing address

5556 UPTON AVE S
MINNEAPOLIS MN
55410-2406
US

V. Phone/Fax

Practice location:
  • Phone: 509-831-9051
  • Fax:
Mailing address:
  • Phone: 509-831-9051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN14033
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN14033
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: