Provider Demographics
NPI:1730459892
Name:CORVALLIS FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:CORVALLIS FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-929-5227
Mailing Address - Street 1:1829 NW KINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1907
Mailing Address - Country:US
Mailing Address - Phone:541-752-5048
Mailing Address - Fax:541-752-9213
Practice Address - Street 1:1829 NW KINGS BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1907
Practice Address - Country:US
Practice Address - Phone:541-752-5048
Practice Address - Fax:541-752-9213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty