Healthcare Provider Details

I. General information

NPI: 1659657799
Provider Name (Legal Business Name): TIDEWATER DENTAL SLEEP THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
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: 866-241-5211
Mailing address:
  • Phone: 301-862-3900
  • Fax: 866-241-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

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