Provider Demographics
NPI:1992749402
Name:POTTER, TYLER J (DDS)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:POTTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10972 ALLISONVILLE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2637
Mailing Address - Country:US
Mailing Address - Phone:317-913-2363
Mailing Address - Fax:317-913-2360
Practice Address - Street 1:1630 W SMITH VALLEY RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1550
Practice Address - Country:US
Practice Address - Phone:317-882-3370
Practice Address - Fax:317-882-2964
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010184A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200449320Medicaid
INU96642Medicare UPIN
IN200449320Medicaid