Provider Demographics
NPI:1992885404
Name:TIDWELL, ANTHONY C (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:C
Last Name:TIDWELL
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 1:4110 HIGHLAND DR
Mailing Address - Street 2:SUITE #200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2676
Mailing Address - Country:US
Mailing Address - Phone:801-278-1164
Mailing Address - Fax:801-274-0124
Practice Address - Street 1:4110 HIGHLAND DR
Practice Address - Street 2:SUITE #200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2676
Practice Address - Country:US
Practice Address - Phone:801-278-1164
Practice Address - Fax:801-274-0124
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT142661122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist