MEDICARE: DR. J DEREK TIEKEN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	16312	TX

General Provider Information

NPI Number	:	1164518007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. J DEREK TIEKEN D.D.S.

Provider Business Mailing Address
First Line	:	3023 MARINA BAY DR
Second Line	:	#105
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-2874
Country	:	US
Telephone Number	:	281-334-4944
Fax Number	:	281-538-3689

Provider Business Practice Location Address
First Line	:	3033 MARINA BAY DR STE 230
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-3982
Country	:	US
Telephone Number	:	281-334-4944
Fax Number	:	281-538-3689

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	01/21/2025

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