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General NPI Number Information
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NPI Number | 1275789950
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Entity Type | Organization
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Legal Business Name | TIDEWATER DENTAL CENTER, PLLC
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Dates
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Enumeration Date | 08/13/2008
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Last Update Date | 08/13/2008
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Provider Practice Location Address
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Address Line | 425 W 20TH ST 3
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City | NORFOLK
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State | VA
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Zip | 23517-2128
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Country | US
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Telephone | 757-622-4245
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Fax | 757-622-3722
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Provider Business Mailing Address
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Address Line | 425 W 20TH ST 3
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City | NORFOLK
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State | VA
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Zip | 23517-2128
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Country | US
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Telephone | 757-622-4245
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Fax | 757-622-3722
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Authorized Official
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Title or Position | VICE PRESIDENT OF OPERATIONS
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Name | MS. AMY D FORD
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Credential |
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Telephone | 757-622-4245
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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 | 0401411261
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License Number State | VA
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