Provider Demographics
NPI:1558308221
Name:TIEDE, SUSAN BON (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:BON
Last Name:TIEDE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 S RESERVE ST STE D
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7652
Mailing Address - Country:US
Mailing Address - Phone:406-541-7337
Mailing Address - Fax:406-541-7338
Practice Address - Street 1:3020 S RESERVE ST STE D
Practice Address - Street 2:SUITE B
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7652
Practice Address - Country:US
Practice Address - Phone:406-541-7334
Practice Address - Fax:406-541-7338
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE58201223P0221X
MT21511223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0113191Medicaid
MT1942483524OtherOFFICE NATIONAL PROVIDER IDENTIFIER