Healthcare Provider Details

I. General information

NPI: 1326296278
Provider Name (Legal Business Name): MICHELLE TYDIR DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 SW 87TH CT SUITE # 212
MIAMI FL
33176-2231
US

IV. Provider business mailing address

5877 SW 26TH ST
MIAMI FL
33155-3124
US

V. Phone/Fax

Practice location:
  • Phone: 305-271-2254
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN 17741
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: