Brock Fred Tidstrom, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

1505 Issued in AK

Practice address

3112 Airport Way
Suite 1
Fairbanks, AK 99709-4754

Phone

(907) 452-1250

NPI assigned

Jul 16, 2013

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in SD

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

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Fairbanks Dental Center LLC

  • Customized Equipment (DME)
  • Fairbanks, AK
  • NPI 1831550631
  NPD (past)

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

{
    "created_epoch": "1373932800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1373932800000",
    "number": "1184065435",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3112 AIRPORT WAY",
            "address_2": "SUITE 1",
            "city": "FAIRBANKS",
            "state": "AK",
            "postal_code": "997094754",
            "telephone_number": "907-452-1250"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3112 AIRPORT WAY",
            "address_2": "SUITE 1",
            "city": "FAIRBANKS",
            "state": "AK",
            "postal_code": "997094754",
            "telephone_number": "907-452-1250"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TIDSTROM",
        "first_name": "BROCK",
        "middle_name": "FRED",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-07-16",
        "last_updated": "2013-07-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "AK",
            "license": "1505",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Louis James Thornley, DDS
• Ruth Diane Thorum, LMSW
• Louise Thurmond
• Roger Dean Thurmond, M.D.,P.C.
• Madalyn Ticknor
• Amond Tilley
• Erin R Tilly, RMT, LMT
• Tiffany Rae Timm, PTA
• Caroline Elizabeth Timmerman, MD
• Sean Michael Timmons, PA-C

• General Practice Dentistry in Fairbanks, AK
• Providers in Fairbanks, AK by specialty
• General Practice Dentistry in Alaska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 16, 2013; 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.