=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750942462
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER SMITH DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2019
-----------------------------------------------------
Last Update Date | 06/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3988 N OCEANA DR
-----------------------------------------------------
City | HART
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49420-8358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-873-9340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5451 BRECKENRIDGE DR
-----------------------------------------------------
City | LUDINGTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-842-5278
-----------------------------------------------------
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 | 2901023213
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------