Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | DE00006884 | WA |
NPI | 1003906835 |
---|---|
Provider Name | Dr. John K. Tidwell |
First Address | Seattle, WA 98107-3987 |
Second Address | Seattle, WA 98107-3987 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2006 |
Last Update Date | 22/10/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U39521 | (02) |