MEDICARE: DR. LARRY G TIEDJE DDS

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	05957	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	099-853	OTHER	IA	DELTA DENTAL IOWA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	702-363	OTHER	IA	TRICARE PROVIDER #

General Provider Information

NPI Number	:	1821046897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY G TIEDJE DDS

Provider Business Mailing Address
First Line	:	2006 PEACHTREE CT
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-1747
Country	:	US
Telephone Number	:	712-252-4013
Fax Number	:

Provider Business Practice Location Address
First Line	:	2410 PIERCE ST
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-3724
Country	:	US
Telephone Number	:	712-255-9056
Fax Number	:	712-255-1526

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

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	07/09/2007

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