MEDICARE: TIDEWATER DENTAL CENTER, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401411261	VA

General Provider Information

NPI Number	:	1275789950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDEWATER DENTAL CENTER, PLLC

Provider Business Mailing Address
First Line	:	425 W 20TH ST
Second Line	:	3
City	:	NORFOLK
State	:	VA
Zip	:	23517-2128
Country	:	US
Telephone Number	:	757-622-4245
Fax Number	:	757-622-3722

Provider Business Practice Location Address
First Line	:	425 W 20TH ST
Second Line	:	3
City	:	NORFOLK
State	:	VA
Zip	:	23517-2128
Country	:	US
Telephone Number	:	757-622-4245
Fax Number	:	757-622-3722

Authorized Official
Title or Position	:	VICE PRESIDENT OF OPERATIONS
Name	:	MS. AMY D FORD
Credential	:
Telephone Number	:	757-622-4245

Provider Enumeration Date	:	08/13/2008
Last Update Date	:	08/13/2008

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