Provider Demographics
NPI:1578724407
Name:VAUGHN GRAY TIDWELL DMD PC
Entity Type:Organization
Organization Name:VAUGHN GRAY TIDWELL DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VAUGHN
Authorized Official - Middle Name:GRAY
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, FICOI
Authorized Official - Phone:503-359-5481
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:SUITE A
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR58481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty