Provider Demographics
NPI:1538153481
Name:TIDWELL, SCOTT ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALAN
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 1:7265 S LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80122-1149
Mailing Address - Country:US
Mailing Address - Phone:720-877-1045
Mailing Address - Fax:303-347-8912
Practice Address - Street 1:8390 W 80TH AVE
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80005-4471
Practice Address - Country:US
Practice Address - Phone:303-425-6419
Practice Address - Fax:303-347-8912
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO66531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice