Provider Demographics
NPI:1396992178
Name:GREEN, TYLER S (DMD)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:S
Last Name:GREEN
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 1:2401 W DOLARWAY RD
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-9309
Mailing Address - Country:US
Mailing Address - Phone:509-925-6553
Mailing Address - Fax:
Practice Address - Street 1:2401 W DOLARWAY RD
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-9309
Practice Address - Country:US
Practice Address - Phone:509-925-6553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60022722122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist