Healthcare Provider Details

I. General information

NPI: 1275789950
Provider Name (Legal Business Name): TIDEWATER DENTAL CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 W 20TH ST 3
NORFOLK VA
23517-2128
US

IV. Provider business mailing address

425 W 20TH ST 3
NORFOLK VA
23517-2128
US

V. Phone/Fax

Practice location:
  • Phone: 757-622-4245
  • Fax: 757-622-3722
Mailing address:
  • Phone: 757-622-4245
  • Fax: 757-622-3722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401411261
License Number StateVA

VIII. Authorized Official

Name: MS. AMY D FORD
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential:
Phone: 757-622-4245