Provider Demographics
NPI:1184065435
Name:TIDSTROM, BROCK FRED (DDS)
Entity type:Individual
Prefix:DR
First Name:BROCK
Middle Name:FRED
Last Name:TIDSTROM
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 1:3112 AIRPORT WAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4754
Mailing Address - Country:US
Mailing Address - Phone:907-452-1250
Mailing Address - Fax:
Practice Address - Street 1:3112 AIRPORT WAY
Practice Address - Street 2:SUITE 1
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4754
Practice Address - Country:US
Practice Address - Phone:907-452-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK15051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice