Provider Demographics
NPI:1124492327
Name:TYLER C PRESTWICH DDS MS PLLC
Entity type:Organization
Organization Name:TYLER C PRESTWICH DDS MS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:C
Authorized Official - Last Name:PRESTWICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PHD, MS
Authorized Official - Phone:701-852-2646
Mailing Address - Street 1:1015 S BROADWAY
Mailing Address - Street 2:SUITE 17
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4667
Mailing Address - Country:US
Mailing Address - Phone:701-852-2646
Mailing Address - Fax:
Practice Address - Street 1:1015 S BROADWAY
Practice Address - Street 2:SUITE 17
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4667
Practice Address - Country:US
Practice Address - Phone:701-852-2646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-25
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND22711223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1465830Medicaid