Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 9283 | NC |
Y | 204E00000X | Oral & Maxillofacial Surgeon | DN24505 | FL |
NPI | 1033484944 |
---|---|
Provider Name | Dr. Tyler James Banachowski |
First Address | Tampa, FL 33621-5023 |
Second Address | Tampa, FL 33621 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2012 |
Last Update Date | 13/09/2019 |