Healthcare Provider Details

I. General information

NPI: 1295179745
Provider Name (Legal Business Name): VICTORIA LANE TIDWELL DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2013
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12385 SORRENTO RD STE B1
PENSACOLA FL
32507-8656
US

IV. Provider business mailing address

7885 NORMANDY BLVD
JACKSONVILLE FL
32221-6640
US

V. Phone/Fax

Practice location:
  • Phone: 850-492-7647
  • Fax:
Mailing address:
  • Phone: 904-783-1633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN 20201
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: