Provider Demographics
NPI:1720898612
Name:ROOT, DYLAN
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:ROOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12517 TATTERSALL PARK LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-3911
Mailing Address - Country:US
Mailing Address - Phone:386-986-7255
Mailing Address - Fax:
Practice Address - Street 1:12517 TATTERSALL PARK LN
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-3911
Practice Address - Country:US
Practice Address - Phone:386-986-7255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program