Provider Demographics
NPI:1326697822
Name:JUDD, TYSA MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TYSA
Middle Name:MARIE
Last Name:JUDD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:TYSA
Other - Middle Name:MARIE
Other - Last Name:TRAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 SUNRISE LOOP #C
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:MT
Mailing Address - Zip Code:59729
Mailing Address - Country:US
Mailing Address - Phone:406-682-3310
Mailing Address - Fax:406-682-3386
Practice Address - Street 1:5 SUNRISE LOOP #C
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:MT
Practice Address - Zip Code:59729
Practice Address - Country:US
Practice Address - Phone:406-682-3310
Practice Address - Fax:406-682-3386
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD110971223G0001X
MTDENDENLIC25828122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice