Provider Demographics
NPI:1932131562
Name:TIDWELL, ERIC IVAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:IVAN
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 1:777 N 500 W STE 101A
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1594
Mailing Address - Country:US
Mailing Address - Phone:801-373-6362
Mailing Address - Fax:801-373-0115
Practice Address - Street 1:777 N 500 W STE 101A
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1594
Practice Address - Country:US
Practice Address - Phone:801-373-6362
Practice Address - Fax:801-373-0115
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1451651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT25762OtherPUBLIC EMPLOYEES HEALTH
UT0005877274OtherAETN
UT145165UTOtherDELTA
UT23820OtherDESERET MUTUAL