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General NPI Number Information
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NPI Number | 1912492364
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Entity Type | Individual
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Provider Name | TYLER WAYNE PHILLIPS DMD
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Gender | Male
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Dates
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Enumeration Date | 06/28/2018
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Last Update Date | 06/28/2018
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Provider Practice Location Address
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Address Line | 305 SW PINE ISLAND RD UNIT 1
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City | CAPE CORAL
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State | FL
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Zip | 33991-2044
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Country | US
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Telephone | 855-623-6023
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Fax |
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Provider Business Mailing Address
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Address Line | 13001 SIMSBURY TER
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City | FORT MYERS
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State | FL
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Zip | 33913-8429
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Country | US
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Telephone | 816-617-6447
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 23555
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License Number State | FL
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