Provider Demographics
NPI:1699799973
Name:TYACK, JAMES HAL (DMD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:HAL
Last Name:TYACK
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:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:CLATSKANIE
Mailing Address - State:OR
Mailing Address - Zip Code:97016-0749
Mailing Address - Country:US
Mailing Address - Phone:503-728-2114
Mailing Address - Fax:
Practice Address - Street 1:400 SW BEL AIR DR.
Practice Address - Street 2:
Practice Address - City:CLATSKANIE
Practice Address - State:OR
Practice Address - Zip Code:97016
Practice Address - Country:US
Practice Address - Phone:503-728-2114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD52261223G0001X
WADE000077601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5043146Medicaid
OR199372Medicaid