Healthcare Provider Details

I. General information

NPI: 1952687360
Provider Name (Legal Business Name): SOUTHERN DELAWARE ASSOCIATES OF DENTAL SPECIALITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2011
Last Update Date: 10/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19323 LIGHTHOUSE PLAZA BLVD UNIT 4
REHOBOTH BEACH DE
19971-6162
US

IV. Provider business mailing address

19323 LIGHTHOUSE PLAZA BLVD UNIT 4
REHOBOTH BEACH DE
19971-6162
US

V. Phone/Fax

Practice location:
  • Phone: 215-880-9919
  • Fax:
Mailing address:
  • Phone: 215-880-9919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number StateDE

VIII. Authorized Official

Name: OTTO TIDWELL
Title or Position: OWNER
Credential: DDS
Phone: 215-880-9919