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General NPI Number Information
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NPI Number | 1932550076
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Entity Type | Individual
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Provider Name | TYLER BRADY DMD
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Gender | Male
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Dates
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Enumeration Date | 06/30/2016
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Last Update Date | 06/30/2016
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Provider Practice Location Address
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Address Line | 808 NE MALL BLVD
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City | HURST
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State | TX
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Zip | 76053-4653
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Country | US
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Telephone | 817-595-9675
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Fax |
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Provider Business Mailing Address
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Address Line | 5436 CHINKAPIN LN
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City | FORT WORTH
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State | TX
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Zip | 76244-6783
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Country | US
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Telephone | 503-312-1598
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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 | 31937
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License Number State | TX
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