Provider Demographics
NPI:1740501410
Name:MURDOCK, TYSON R (DMD)
Entity type:Individual
Prefix:DR
First Name:TYSON
Middle Name:R
Last Name:MURDOCK
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 1:3955 GEORGIA LN
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-7812
Mailing Address - Country:US
Mailing Address - Phone:208-419-9570
Mailing Address - Fax:208-523-4441
Practice Address - Street 1:2205 CHANNING WAY
Practice Address - Street 2:SUITE A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8016
Practice Address - Country:US
Practice Address - Phone:208-529-4484
Practice Address - Fax:208-523-4441
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD43021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice