=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508344185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY TYRA SNYDER DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2018
-----------------------------------------------------
Last Update Date | 08/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1316 JACKIE RD SE STE 200
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-1045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-994-9693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6023 W KERRY LN
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-7690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-440-2828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DD4966
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------