=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760945224
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER JAMES GUINN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2019
-----------------------------------------------------
Last Update Date | 05/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3366 BURTON ST SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-4353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-949-3541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7701 GATEHEAD DR
-----------------------------------------------------
City | JENISON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49428-9111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-322-4810
-----------------------------------------------------
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 | 2901022678
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------