Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 11651266-9923 | UT |
N | 1223P0221X | Pediatric Dentist | D11034 | OR |
NPI | 1023545951 |
---|---|
Provider Name | Dr. Tyler Dale Hanks |
First Address | Millcreek, UT 84109 |
Second Address | Millcreek, UT 84109 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2017 |
Last Update Date | 16/10/2020 |