Provider Demographics
NPI:1962081471
Name:EDDY, AUSTIN TYLER (DMD)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:TYLER
Last Name:EDDY
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 1:115 N BEECH ST
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3207
Mailing Address - Country:US
Mailing Address - Phone:970-565-7275
Mailing Address - Fax:
Practice Address - Street 1:510 E LISA DR
Practice Address - Street 2:
Practice Address - City:CHAPARRAL
Practice Address - State:NM
Practice Address - Zip Code:88081-7809
Practice Address - Country:US
Practice Address - Phone:575-824-0128
Practice Address - Fax:575-824-0179
Is Sole Proprietor?:No
Enumeration Date:2021-04-03
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD5457122300000X
CO00205514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist