Healthcare Provider Details

I. General information

NPI: 1235642984
Provider Name (Legal Business Name): TIDEWATER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21534 GREAT MILLS RD
LEXINGTON PARK MD
20653-1204
US

IV. Provider business mailing address

21534 GREAT MILLS RD
LEXINGTON PARK MD
20653-1204
US

V. Phone/Fax

Practice location:
  • Phone: 301-862-3900
  • Fax: 301-862-3779
Mailing address:
  • Phone: 301-862-3900
  • Fax: 301-862-3779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateMD

VIII. Authorized Official

Name: DR. DAVID COOPER
Title or Position: OWNER
Credential: DDS
Phone: 301-862-3900