Provider Demographics
NPI:1548520570
Name:AHOLT, TYLER MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:MICHAEL
Last Name:AHOLT
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 1:4620 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2714
Mailing Address - Country:US
Mailing Address - Phone:314-752-7468
Mailing Address - Fax:314-752-5168
Practice Address - Street 1:4620 HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-2714
Practice Address - Country:US
Practice Address - Phone:314-752-7468
Practice Address - Fax:314-752-5168
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120156621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice