Healthcare Provider Details

I. General information

NPI: 1366836835
Provider Name (Legal Business Name): TYLER BRENT WHITING DMD, BS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4122 QUEST DR
EUGENE OR
97402
US

IV. Provider business mailing address

4122 QUEST DR
EUGENE OR
97402-8768
US

V. Phone/Fax

Practice location:
  • Phone: 541-844-1667
  • Fax: 541-505-8463
Mailing address:
  • Phone: 541-844-1667
  • Fax: 541-505-8463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD009666
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10985
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierD09666
Identifier TypeOTHER
Identifier StateAZ
Identifier IssuerDENTAL LICENSE
# 2
IdentifierD10985
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerDENTAL LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: