MEDICARE: DR. IAN STUART TYDEMAN DMD

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	1223G0001X	General Practice Dentistry	D9162	OR

General Provider Information

NPI Number	:	1689830556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IAN STUART TYDEMAN DMD

Provider Business Mailing Address
First Line	:	14800 KRUSE OAKS BLVD
Second Line	:	SUITE A
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-8603
Country	:	US
Telephone Number	:	503-684-2944
Fax Number	:

Provider Business Practice Location Address
First Line	:	14800 KRUSE OAKS BLVD
Second Line	:	SUITE A
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-8603
Country	:	US
Telephone Number	:	503-684-2944
Fax Number	:

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

Provider Enumeration Date	:	07/31/2008
Last Update Date	:	07/31/2008

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