Provider Demographics
NPI:1174380836
Name:MARANA PEDIATRIC DENTISTRY, TYLER ROBERTS, DMD, PLLC
Entity type:Organization
Organization Name:MARANA PEDIATRIC DENTISTRY, TYLER ROBERTS, DMD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-536-5087
Mailing Address - Street 1:2165 N DORAN
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-2081
Mailing Address - Country:US
Mailing Address - Phone:401-536-5087
Mailing Address - Fax:
Practice Address - Street 1:6239 E BROWN RD STE 102
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4933
Practice Address - Country:US
Practice Address - Phone:480-753-3711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-29
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty