Provider Demographics
NPI:1215618673
Name:CHRISTIANSEN, TYLER CRAIG (DMD)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:CRAIG
Last Name:CHRISTIANSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4430 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-9098
Mailing Address - Country:US
Mailing Address - Phone:573-596-0417
Mailing Address - Fax:
Practice Address - Street 1:6958 NEBRASKA AVE BLDG 1608
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-1618
Practice Address - Country:US
Practice Address - Phone:573-596-0364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023023294122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist