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General NPI Number Information
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NPI Number | 1053607002
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Entity Type | Organization
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Legal Business Name | TIDEWATER DENTAL PF
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Dates
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Enumeration Date | 06/28/2011
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Last Update Date | 06/28/2011
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Provider Practice Location Address
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Address Line | 690 PRINCE FREDERICK BLVD
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City | PRINCE FREDERICK
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State | MD
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Zip | 20678
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Country | US
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Telephone | 410-414-8333
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Fax | 301-862-3779
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Provider Business Mailing Address
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Address Line | 690 PRINCE FREDERICK BLVD
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City | PRINCE FREDERICK
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State | MD
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Zip | 20678
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Country | US
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Telephone | 410-414-8333
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Fax | 301-862-3779
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. CONNIE M MCCABE
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Credential |
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Telephone | 301-862-3900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 14501
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 6466
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License Number State | MD
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