Healthcare Provider Details

I. General information

NPI: 1326697822
Provider Name (Legal Business Name): TYSA MARIE JUDD DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. TYSA MARIE TRAMP

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W KOCH ST STE 1
BOZEMAN MT
59715-4148
US

IV. Provider business mailing address

1700 W KOCH ST STE 1
BOZEMAN MT
59715-4148
US

V. Phone/Fax

Practice location:
  • Phone: 406-586-4559
  • Fax:
Mailing address:
  • Phone: 406-586-4559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDENDENLIC25828
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD11097
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: