Provider Demographics
NPI:1477049989
Name:TIDWELL, JAMIE RENEE (LDH)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:RENEE
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:LDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:CAYUGA
Mailing Address - State:IN
Mailing Address - Zip Code:47928-0209
Mailing Address - Country:US
Mailing Address - Phone:765-492-8099
Mailing Address - Fax:765-492-9048
Practice Address - Street 1:703 W PARK ST
Practice Address - Street 2:
Practice Address - City:CAYUGA
Practice Address - State:IN
Practice Address - Zip Code:47928-8207
Practice Address - Country:US
Practice Address - Phone:765-492-8099
Practice Address - Fax:765-492-9048
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13005947A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist