MEDICARE: DR. JOEL KIRK TIDWELL D.D.S.

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	1223G0001X	General Practice Dentistry	16401	TX

General Provider Information

NPI Number	:	1619099454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOEL KIRK TIDWELL D.D.S.

Provider Business Mailing Address
First Line	:	581 PAN AMERICAN DR
Second Line	:	SUITE 4
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-1960
Country	:	US
Telephone Number	:	254-680-5551
Fax Number	:	254-680-3397

Provider Business Practice Location Address
First Line	:	581 PAN AMERICAN DR
Second Line	:	SUITE 4
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-1960
Country	:	US
Telephone Number	:	254-680-5551
Fax Number	:	254-680-3397

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	07/08/2007

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