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General NPI Number Information
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NPI Number | 1891915112
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTAL CARE OF TIDEWATER PC
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Dates
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Enumeration Date | 04/27/2007
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Last Update Date | 01/03/2025
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Provider Practice Location Address
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Address Line | 5915 HIGH STREET WEST
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City | PORTSMOUTH
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State | VA
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Zip | 23703
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Country | US
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Telephone | 757-484-8262
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Fax | 757-638-3632
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Provider Business Mailing Address
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Address Line | 5915 HIGH ST W
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City | PORTSMOUTH
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State | VA
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Zip | 23703-4505
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Country | US
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Telephone | 757-484-8262
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Fax | 757-638-3632
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Authorized Official
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Title or Position | OWNER
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Name | MORGAN TREY WEIS
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Credential |
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Telephone | 757-484-8262
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 0401410496
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License Number State | VA
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