Provider Demographics
NPI:1033953625
Name:TOLBERT, AUSTIN TYLER (DDS)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:TYLER
Last Name:TOLBERT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 N 147TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74116-2602
Mailing Address - Country:US
Mailing Address - Phone:918-237-1917
Mailing Address - Fax:
Practice Address - Street 1:2036 S MILLER LN STE B
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-1539
Practice Address - Country:US
Practice Address - Phone:918-937-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK79191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice