Healthcare Provider Details

I. General information

NPI: 1033022272
Provider Name (Legal Business Name): TIDEWATER DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10104 FORD AVE STE G2
RICHMOND HILL GA
31324-8850
US

IV. Provider business mailing address

308 KERRY DR
RICHMOND HILL GA
31324-9210
US

V. Phone/Fax

Practice location:
  • Phone: 207-991-1064
  • Fax:
Mailing address:
  • Phone: 207-991-1064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHRISTOPHER PARENT
Title or Position: DENTIST
Credential: DMD
Phone: 207-991-1064