Provider Demographics
NPI:1104173244
Name:MAYERLE & TYDEMAN, LLC
Entity type:Organization
Organization Name:MAYERLE & TYDEMAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:TYDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-577-3168
Mailing Address - Street 1:14800 KRUSE OAKS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8671
Mailing Address - Country:US
Mailing Address - Phone:503-684-2944
Mailing Address - Fax:503-624-6335
Practice Address - Street 1:14800 KRUSE OAKS BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-8671
Practice Address - Country:US
Practice Address - Phone:503-684-2944
Practice Address - Fax:503-624-6335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9162122300000X
ORD6896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty