Healthcare Provider Details

I. General information

NPI: 1801001987
Provider Name (Legal Business Name): STEVEN DAVID TIDWELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 W NEZ PERCE
JEROME ID
83338-5077
US

IV. Provider business mailing address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

V. Phone/Fax

Practice location:
  • Phone: 208-324-3471
  • Fax:
Mailing address:
  • Phone: 208-734-3312
  • Fax: 208-734-5036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5242
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number29502
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: