Provider Demographics
NPI:1245668631
Name:JOHN K TIDWELL DDS PS
Entity type:Organization
Organization Name:JOHN K TIDWELL DDS PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-783-9672
Mailing Address - Street 1:1801 NW MARKET ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-3987
Mailing Address - Country:US
Mailing Address - Phone:206-783-9672
Mailing Address - Fax:
Practice Address - Street 1:1801 NW MARKET ST
Practice Address - Street 2:SUITE 108
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3987
Practice Address - Country:US
Practice Address - Phone:206-783-9672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000068841223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty