Individual
DR. ERIC IVAN TIDWELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
777 N 500 W STE 101A, PROVO, UT 84601-1594
(801) 373-6362
(801) 373-0115
Mailing address
777 N 500 W STE 101A, PROVO, UT 84601-1594
(801) 373-6362
(801) 373-0115
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
145165
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0005877274
AETN
UT
01
—
145165UT
DELTA
UT
01
—
23820
DESERET MUTUAL
UT
01
—
25762
PUBLIC EMPLOYEES HEALTH
UT
Enumeration date
07/06/2006
Last updated
07/08/2007
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