Healthcare Provider Details

I. General information

NPI: 1972163590
Provider Name (Legal Business Name): TYLERE NUNNERY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

53 NORTHTOWN DR APT 32C
JACKSON MS
39211-3801
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6028
  • Fax: 601-984-6039
Mailing address:
  • Phone: 601-551-9009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4062-19
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: