Provider Demographics
NPI:1487699534
Name:TYSON, JOHN T (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:TYSON
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 1:19874 WILKINSON LEAS RD
Mailing Address - Street 2:
Mailing Address - City:TEQUESTA
Mailing Address - State:FL
Mailing Address - Zip Code:33469-2178
Mailing Address - Country:US
Mailing Address - Phone:561-746-7702
Mailing Address - Fax:561-746-6355
Practice Address - Street 1:2614 SE WILLOUGHBY BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4700
Practice Address - Country:US
Practice Address - Phone:772-283-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN9494122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist