Provider Demographics
NPI:1427311505
Name:TYE, CHRISTOPHER L (MD DDS)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:L
Last Name:TYE
Suffix:
Gender:M
Credentials:MD DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6904 COLLEYVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6288
Mailing Address - Country:US
Mailing Address - Phone:817-552-3223
Mailing Address - Fax:817-552-3224
Practice Address - Street 1:6904 COLLEYVILLE BLVD
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6288
Practice Address - Country:US
Practice Address - Phone:817-552-3223
Practice Address - Fax:817-552-3224
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15676204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110918303Medicaid
TX110918303Medicaid