Provider Demographics
NPI:1396274429
Name:WALLINGFORD, TYLER STEVEN (DDS)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:STEVEN
Last Name:WALLINGFORD
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 1:402 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC
Mailing Address - State:IA
Mailing Address - Zip Code:50022-1250
Mailing Address - Country:US
Mailing Address - Phone:712-243-3275
Mailing Address - Fax:712-243-8024
Practice Address - Street 1:402 POPLAR ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-1250
Practice Address - Country:US
Practice Address - Phone:712-243-3275
Practice Address - Fax:712-243-8024
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-09431122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist