=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477228468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER MOYLE DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2021
-----------------------------------------------------
Last Update Date | 08/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2045 W BRIGGSMORE AVE
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-3767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-975-7815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7013 DAKOTA DR
-----------------------------------------------------
City | WEST DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50266-2410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-975-7815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 106832
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------