Provider Demographics
NPI:1538390042
Name:CARMACK, TYLER (DMD)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:CARMACK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 VT ROUTE 7A
Mailing Address - Street 2:
Mailing Address - City:SHAFTSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05262-9548
Mailing Address - Country:US
Mailing Address - Phone:802-442-7300
Mailing Address - Fax:802-442-7117
Practice Address - Street 1:677 VT ROUTE 7A
Practice Address - Street 2:
Practice Address - City:SHAFTSBURY
Practice Address - State:VT
Practice Address - Zip Code:05262-9548
Practice Address - Country:US
Practice Address - Phone:802-442-7300
Practice Address - Fax:802-442-7117
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0100771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice