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General NPI Number Information
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NPI Number | 1396196481
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Entity Type | Organization
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Legal Business Name | DR. MATT TYSON, DDS, PC
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Dates
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Enumeration Date | 06/29/2016
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Last Update Date | 06/29/2016
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Provider Practice Location Address
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Address Line | 8113 CAMP BOWIE WEST BLVD
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City | BENBROOK
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State | TX
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Zip | 76116-6314
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Country | US
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Telephone | 817-560-9300
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Fax | 817-560-9303
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Provider Business Mailing Address
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Address Line | 8113 CAMP BOWIE WEST BLVD
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City | BENBROOK
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State | TX
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Zip | 76116-6314
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Country | US
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Telephone | 817-560-9300
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Fax | 817-560-9303
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MATT A TYSON
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Credential | D.D.D
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Telephone | 214-675-9116
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 24696
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License Number State | TX
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