Healthcare Provider Details

I. General information

NPI: 1376809129
Provider Name (Legal Business Name): TJ DYER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 OLD SAUK RD
MADISON WI
53717-2307
US

IV. Provider business mailing address

7007 OLD SAUK RD
MADISON WI
53717-2307
US

V. Phone/Fax

Practice location:
  • Phone: 608-819-8760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1001229-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL11594
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: