Healthcare Provider Details

I. General information

NPI: 1346478765
Provider Name (Legal Business Name): DARREN TIDWELL DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 W MAIN ST
WILBURTON OK
74578-4045
US

IV. Provider business mailing address

225 W MAIN ST
WILBURTON OK
74578-4045
US

V. Phone/Fax

Practice location:
  • Phone: 918-465-9300
  • Fax: 918-465-9303
Mailing address:
  • Phone: 918-465-9300
  • Fax: 918-465-9303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11475
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: