Healthcare Provider Details

I. General information

NPI: 1144884560
Provider Name (Legal Business Name): TIDEWATER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30320 TRIANGLE DR
CHARLOTTE HALL MD
20622-4109
US

IV. Provider business mailing address

21534 GREAT MILLS RD
LEXINGTON PARK MD
20653-1204
US

V. Phone/Fax

Practice location:
  • Phone: 301-359-1717
  • Fax: 301-359-1719
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SIMONE WILSON
Title or Position: DIRECTOR OF CREDENTIALING & ENROLL
Credential:
Phone: 848-326-8840