Healthcare Provider Details

I. General information

NPI: 1306361092
Provider Name (Legal Business Name): TIDEWATER DENTISTRY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 N PINE ST
SUMMERVILLE SC
29483-6555
US

IV. Provider business mailing address

503 N PINE ST
SUMMERVILLE SC
29483-6554
US

V. Phone/Fax

Practice location:
  • Phone: 843-871-5394
  • Fax:
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: DR. JAMES REED WILLIAMSON
Title or Position: PRESIDENT
Credential: DMD
Phone: 843-873-1646