Provider Demographics
NPI:1063553410
Name:TIEDEMAN, THOMAS LEONARD (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LEONARD
Last Name:TIEDEMAN
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 1:2918 HAMILTON BLVD
Mailing Address - Street 2:UPPER D SUITE 1
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104
Mailing Address - Country:US
Mailing Address - Phone:712-255-1163
Mailing Address - Fax:712-252-6157
Practice Address - Street 1:2918 HAMILTON BLVD
Practice Address - Street 2:UPPER D SUITE 1
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104
Practice Address - Country:US
Practice Address - Phone:712-255-1163
Practice Address - Fax:712-252-6157
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA059441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0055947Medicaid