Healthcare Provider Details

I. General information

NPI: 1073287132
Provider Name (Legal Business Name): TYLER ELWOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S 200 E STE 250
SALT LAKE CITY UT
84111-3846
US

IV. Provider business mailing address

660 S 200 E STE 250
SALT LAKE CITY UT
84111-3846
US

V. Phone/Fax

Practice location:
  • Phone: 801-356-2256
  • Fax:
Mailing address:
  • Phone: 801-359-2256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12730935-9921
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD011074
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: