Individual
DR. DALE ROGER TIDABACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD, MPH
Contact information
Practice address
4881 SUGAR MAPLE DR, WRIGHT PATTERSON AFB, OH 45433-5529
(703) 994-8148
Mailing address
9200 ARMETALE CT, FAIRFAX STATION, VA 22039-3111
(703) 690-1448
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
1559
SD
2083A0100X
Aerospace Medicine Physician
Primary
1559
SD
Other
Enumeration date
12/21/2005
Last updated
12/02/2014
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