Provider Demographics
NPI:1265059091
Name:TIDWELL, AUSTIN (DMD)
Entity type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:
Last Name:TIDWELL
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 1:3040 N CULLEN CT
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-9443
Mailing Address - Country:US
Mailing Address - Phone:801-358-2230
Mailing Address - Fax:
Practice Address - Street 1:1082N N NORTHCOUNTY BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3400
Practice Address - Country:US
Practice Address - Phone:801-756-6048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-27
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7421122300000X
NVLL-538-201223G0001X
UT12772511-99221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice