Provider Demographics
NPI:1326252412
Name:DENNIS A TIDWELL PA
Entity Type:Organization
Organization Name:DENNIS A TIDWELL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-835-1734
Mailing Address - Street 1:3454 GAINESVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-6501
Mailing Address - Country:US
Mailing Address - Phone:706-835-1734
Mailing Address - Fax:
Practice Address - Street 1:3454 GAINESVILLE HWY
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-6501
Practice Address - Country:US
Practice Address - Phone:706-835-1734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4284Medicare ID - Type Unspecified