Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DE60212723 | WA |
NPI | 1003115841 |
---|---|
Provider Name | Dr. Tyler Alan Fordham |
First Address | Yakima, WA 98908-2707 |
Second Address | Yakima, WA 98908-2707 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/03/2011 |
Last Update Date | 18/03/2011 |