Provider Demographics
NPI:1104053057
Name:DAVIS, TYLER MATHESON (DDS)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:MATHESON
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-2808
Mailing Address - Country:US
Mailing Address - Phone:919-556-3780
Mailing Address - Fax:919-556-1708
Practice Address - Street 1:814 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-2808
Practice Address - Country:US
Practice Address - Phone:919-556-3780
Practice Address - Fax:919-556-1708
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8811332B00000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies