Active NPI
Tyler Antonelli, DDS
- Dentist
- Davis-Monthan Afb, AZ
National Provider Identifier
1073133393
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 11977
- Practice address
- 4175 S Alamo Ave
Davis-Monthan Afb, AZ 85707 - Phone
- (910) 619-6720
- NPI assigned
- Apr 17, 2020
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 11977 | NC | Primary |
Addresses
Primary practice location
4175 S Alamo Ave
Davis-Monthan Afb, AZ 85707
Mailing address
4175 S Alamo Ave
Davis-Monthan Afb, AZ 85707
Phone (910) 619-6720
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11977 | NC | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1587081600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1632096000000",
"number": "1073133393",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4175 S ALAMO AVE",
"city": "DAVIS-MONTHAN AFB",
"state": "AZ",
"postal_code": "85707",
"telephone_number": "910-619-6720"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4175 S ALAMO AVE",
"city": "DAVIS-MONTHAN AFB",
"state": "AZ",
"postal_code": "85707",
"telephone_number": "910-619-6720"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ANTONELLI",
"first_name": "TYLER",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2020-04-17",
"last_updated": "2021-09-20",
"certification_date": "2021-09-01",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "NC",
"license": "11977",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Davis-Monthan Afb, AZ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 20, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.