Provider Demographics
NPI:1619099454
Name:TIDWELL, JOEL KIRK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:KIRK
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:581 PAN AMERICAN DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-1960
Mailing Address - Country:US
Mailing Address - Phone:254-680-5551
Mailing Address - Fax:254-680-3397
Practice Address - Street 1:581 PAN AMERICAN DR
Practice Address - Street 2:SUITE 4
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1960
Practice Address - Country:US
Practice Address - Phone:254-680-5551
Practice Address - Fax:254-680-3397
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX164011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice