Provider Demographics
NPI:1083600753
Name:TIDWELL, VAUGHN G (DMD)
Entity Type:Individual
Prefix:
First Name:VAUGHN
Middle Name:G
Last Name:TIDWELL
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 1:2236 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-2448
Mailing Address - Country:US
Mailing Address - Phone:503-359-5481
Mailing Address - Fax:503-359-7882
Practice Address - Street 1:2236 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2448
Practice Address - Country:US
Practice Address - Phone:503-359-5481
Practice Address - Fax:503-359-7882
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR58481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice