Provider Demographics
NPI:1770272163
Name:STIDHAM, TYLER KEITH (DMD, MBA)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:KEITH
Last Name:STIDHAM
Suffix:
Gender:M
Credentials:DMD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2628 CLOVERLANE DR
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-9497
Mailing Address - Country:US
Mailing Address - Phone:740-935-4258
Mailing Address - Fax:
Practice Address - Street 1:8714 TENNYSON AVE
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1932
Practice Address - Country:US
Practice Address - Phone:740-370-1992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.027614122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist