MEDICARE: KENNETH K TYER SR. D.D.S.

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	6762	TX

General Provider Information

NPI Number	:	1609883396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH K TYER SR. D.D.S.

Provider Business Mailing Address
First Line	:	2121 TIMBERLANE ST STE A
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77301-1106
Country	:	US
Telephone Number	:	936-756-1443
Fax Number	:	936-756-1406

Provider Business Practice Location Address
First Line	:	2121 TIMBERLANE ST STE A
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77301-1176
Country	:	US
Telephone Number	:	936-756-1443
Fax Number	:	936-756-1406

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	07/08/2007

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