MEDICARE: DR. TYLER A. GRAHAM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1549	WY

General Provider Information

NPI Number	:	1053934182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TYLER A. GRAHAM DDS

Provider Business Mailing Address
First Line	:	325 W MAIN ST STE G
Second Line	:
City	:	RIVERTON
State	:	WY
Zip	:	82501-3448
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	325 W MAIN ST STE G
Second Line	:
City	:	RIVERTON
State	:	WY
Zip	:	82501-3448
Country	:	US
Telephone Number	:	307-856-5210
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2020
Last Update Date	:	05/23/2020

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