Active NPI
Tyrel Larsen
- Orthodontics and Dentofacial Orthopedics Dentistry
- Marion, IL
National Provider Identifier
1396366381
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Orthodontics and Dentofacial Orthopedics Dentistry
- License
- 021.003269
- Practice address
- 3108 W Deyoung St Ste a
Marion, IL 62959-5548 - Phone
- (479) 254-0669
- NPI assigned
- Apr 30, 2020
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | DS035312 | PA | |
| Orthodontics and Dentofacial Orthopedics Dentistry | 1223X0400X | 021.003269 | IL | Primary |
Addresses
Primary practice location
3108 W Deyoung St Ste a
Marion, IL 62959-5548
Mailing address
3108 W Deyoung St Ste a
Marion, IL 62959-5548
Phone (479) 254-0669
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 |
|---|---|---|---|
| 021.003269 | IL | MD | Orthodontics and Dentofacial Orthopedic Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1588204800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1700006400000",
"number": "1396366381",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3108 W DEYOUNG ST STE A",
"city": "MARION",
"state": "IL",
"postal_code": "629595548",
"telephone_number": "479-254-0669"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3108 W DEYOUNG ST STE A",
"city": "MARION",
"state": "IL",
"postal_code": "629595548",
"telephone_number": "479-254-0669"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LARSEN",
"first_name": "TYREL",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-04-30",
"last_updated": "2023-11-15",
"certification_date": "2023-11-14",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": "PA",
"license": "DS035312",
"primary": false
},
{
"code": "1223X0400X",
"taxonomy_group": "",
"desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
"state": "IL",
"license": "021.003269",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Marion, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.