Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 6985 | LA |
NPI | 1225697196 |
---|---|
Provider Name | Stephen Tyer |
First Address | Shreveport, LA 71105-4257 |
Second Address | Shreveport, LA 71105-4257 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2019 |
Last Update Date | 13/06/2019 |