Healthcare Provider Details

I. General information

NPI: 1366921389
Provider Name (Legal Business Name): TYLER A DUFFY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 WILSON ST., OFFICE GD152
FT SILL OK
73503
US

IV. Provider business mailing address

4301 WILSON ST., OFFICE GD152
FT SILL OK
73503
US

V. Phone/Fax

Practice location:
  • Phone: 580-558-2795
  • Fax:
Mailing address:
  • Phone: 580-558-2795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number10835129-9922
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7393
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: