Healthcare Provider Details

I. General information

NPI: 1477049989
Provider Name (Legal Business Name): JAMIE RENEE TIDWELL LDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1792 E STATE ROAD 163
CLINTON IN
47842-7327
US

IV. Provider business mailing address

1792 E STATE ROAD 163
CLINTON IN
47842-7327
US

V. Phone/Fax

Practice location:
  • Phone: 765-828-3241
  • Fax: 765-828-3243
Mailing address:
  • Phone: 765-828-3241
  • Fax: 765-828-3243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number13005947A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: