Provider Demographics
NPI:1689830556
Name:TYDEMAN, IAN STUART (DMD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:STUART
Last Name:TYDEMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14800 KRUSE OAKS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8603
Mailing Address - Country:US
Mailing Address - Phone:503-684-2944
Mailing Address - Fax:
Practice Address - Street 1:14800 KRUSE OAKS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-8603
Practice Address - Country:US
Practice Address - Phone:503-684-2944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD91621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice