Individual
DR. LARRY G TIEDJE
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
2410 PIERCE ST, SIOUX CITY, IA 51104-3724
(712) 255-9056
(712) 255-1526
Mailing address
2006 PEACHTREE CT, SIOUX CITY, IA 51104-1747
(712) 252-4013
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
05957
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0087882
—
IA
01
—
099-853
DELTA DENTAL IOWA
IA
01
—
702-363
TRICARE PROVIDER #
IA
Enumeration date
05/04/2006
Last updated
07/09/2007
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