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General NPI Number Information
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NPI Number | 1144884560
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Entity Type | Organization
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Legal Business Name | TIDEWATER LLC
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Dates
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Enumeration Date | 05/01/2019
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Last Update Date | 05/02/2023
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Provider Practice Location Address
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Address Line | 30320 TRIANGLE DR
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City | CHARLOTTE HALL
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State | MD
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Zip | 20622-4109
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Country | US
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Telephone | 301-359-1717
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Fax | 301-359-1719
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Provider Business Mailing Address
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Address Line | 21534 GREAT MILLS RD
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City | LEXINGTON PARK
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State | MD
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Zip | 20653-1204
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF CREDENTIALING & ENROLL
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Name | SIMONE WILSON
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Credential |
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Telephone | 848-326-8840
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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