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General NPI Number Information
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NPI Number | 1104173244
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Entity Type | Organization
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Legal Business Name | MAYERLE & TYDEMAN, LLC
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Dates
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Enumeration Date | 08/08/2012
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Last Update Date | 08/08/2012
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Provider Practice Location Address
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Address Line | 14800 KRUSE OAKS BLVD STE A
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-8671
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Country | US
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Telephone | 503-684-2944
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Fax | 503-624-6335
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Provider Business Mailing Address
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Address Line | 14800 KRUSE OAKS BLVD STE A
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-8671
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Country | US
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Telephone | 503-684-2944
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Fax | 503-624-6335
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Authorized Official
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Title or Position | DENTIST
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Name | DR. IAN STUART TYDEMAN
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Credential | DMD
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Telephone | 503-577-3168
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D9162
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D6896
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License Number State | OR
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