1124492327 NPI number — TYLER C PRESTWICH DDS MS PLLC

Table of content: (NPI 1124492327)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124492327 NPI number — TYLER C PRESTWICH DDS MS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TYLER C PRESTWICH DDS MS PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124492327
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1015 S BROADWAY
Provider Second Line Business Mailing Address:
SUITE 17
Provider Business Mailing Address City Name:
MINOT
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58701-4667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-852-2646
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 S BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 17
Provider Business Practice Location Address City Name:
MINOT
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58701-4667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-852-2646
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PRESTWICH
Authorized Official First Name:
TYLER
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
701-852-2646

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  2271 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1465830 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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