Provider Demographics
NPI:1134625114
Name:MESA, TYLER ROBERTO (DDS)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:ROBERTO
Last Name:MESA
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 1:1829 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-5917
Mailing Address - Country:US
Mailing Address - Phone:985-705-8144
Mailing Address - Fax:
Practice Address - Street 1:189 GREENBRIER BLVD STE A
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7297
Practice Address - Country:US
Practice Address - Phone:985-892-5942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA68551223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program