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General NPI Number Information
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NPI Number | 1740501410
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Entity Type | Individual
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Provider Name | TYSON R MURDOCK D.M.D
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Gender | Male
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Dates
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Enumeration Date | 06/17/2010
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Last Update Date | 06/17/2010
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Provider Practice Location Address
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Address Line | 2205 CHANNING WAY SUITE A
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8016
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Country | US
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Telephone | 208-529-4484
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Fax | 208-523-4441
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Provider Business Mailing Address
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Address Line | 3955 GEORGIA LN
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City | AMMON
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State | ID
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Zip | 83406-7812
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Country | US
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Telephone | 208-419-9570
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Fax | 208-523-4441
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D4302
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License Number State | ID
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