Bill Shayne Tidwell, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

6993 Issued in KS

Practice address

Corner of Route N12 and N7
Fort Defiance, AZ 86504-0589

Phone

(928) 729-8000

NPI assigned

Jan 19, 2006

Last updated

Oct 18, 2019By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in CO

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1137628800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1571356800000",
    "number": "1053391797",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1801",
            "city": "FORT DEFIANCE",
            "state": "AZ",
            "postal_code": "865041801",
            "telephone_number": "928-729-8000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "CORNER OF ROUTE N12 AND N7",
            "city": "FORT DEFIANCE",
            "state": "AZ",
            "postal_code": "865040589",
            "telephone_number": "928-729-8000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TIDWELL",
        "first_name": "BILL",
        "middle_name": "SHAYNE",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-01-19",
        "last_updated": "2019-10-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "AK",
            "license": "117592",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CO",
            "license": "7367",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "TX",
            "license": "14581",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "KS",
            "license": "6993",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100454590A",
            "state": "KS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FEDERAL EMPLOYER  NUMBER",
            "identifier": "48-1181104",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• John R Thompson, M.D.
• Naomi Howry Thompson, PHARMD.
• Sally Lynn Thompson, PA-C
• Amber Marie Thurman, CRT
• Lydia Nakitto Thurmond
• Martha N. Toadlena, LISAC
• Valora Jean Tom, RD, LD, CDE
• Dieumy Tonnu, PHARMD
• Brian Mitchell Mitchell Torres Ortiz, RN
• Jesse Trujillo

• General Practice Dentistry in Fort Defiance, AZ
• Providers in Fort Defiance, AZ by specialty
• General Practice Dentistry in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.