MEDICARE: TIDWELL DENTAL AND ORTHODONTICS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1033752480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDWELL DENTAL AND ORTHODONTICS PLLC

Provider Business Mailing Address
First Line	:	5422 NORTH FWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77076-4701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5422 NORTH FWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77076-4701
Country	:	US
Telephone Number	:	817-529-8151
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SAAM ZARRABI
Credential	:
Telephone Number	:	817-529-8151

Provider Enumeration Date	:	10/17/2019
Last Update Date	:	10/17/2019

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