Provider Demographics
NPI:1386790848
Name:TIDWELL, JOEL RAY (DDS)
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:RAY
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5897 STEWART PKWY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-2373
Mailing Address - Country:US
Mailing Address - Phone:770-949-1821
Mailing Address - Fax:770-942-2837
Practice Address - Street 1:5897 STEWART PKWY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-2373
Practice Address - Country:US
Practice Address - Phone:770-949-1821
Practice Address - Fax:770-942-2837
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN009481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist