Healthcare Provider Details

I. General information

NPI: 1538390042
Provider Name (Legal Business Name): TYLER CARMACK D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 VT ROUTE 7A
SHAFTSBURY VT
05262-9548
US

IV. Provider business mailing address

677 VT ROUTE 7A
SHAFTSBURY VT
05262-9548
US

V. Phone/Fax

Practice location:
  • Phone: 802-442-7300
  • Fax: 802-442-7117
Mailing address:
  • Phone: 802-442-7300
  • Fax: 802-442-7117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number010077
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: