Provider Demographics
NPI:1326697822
Name:JUDD, TYSA MARIE (DMD)
Entity type:Individual
Prefix:DR
First Name:TYSA
Middle Name:MARIE
Last Name:JUDD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MS
Other - First Name:TYSA
Other - Middle Name:MARIE
Other - Last Name:TRAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 W KOCH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-4148
Mailing Address - Country:US
Mailing Address - Phone:406-586-4559
Mailing Address - Fax:
Practice Address - Street 1:1700 W KOCH ST STE 1
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4148
Practice Address - Country:US
Practice Address - Phone:406-586-4559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD110971223G0001X
MTDENDENLIC25828122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice