Tidewater LLC
NPI #1144884560 in Charlotte Hall, Maryland
Provider Information
- NPI Number
- 1144884560
- Entity Type
- Organization
- Organization Name
- Tidewater LLC
- Subpart
- Yes (part of a larger organization)
- Parent Organization
- TIDEWATER, LLC
- Primary Specialty
- Dentist - General Practice
- Enumeration Date
- May 1, 2019
- Last Updated
- May 2, 2023
Practice Location
- Address
- 30320 TRIANGLE DR
- City
- Charlotte Hall
- State
- Maryland
- ZIP Code
- 20622-4109
- Phone
- (301) 359-1717
Authorized Official
- Name
- SIMONE WILSON
- Title
- DIRECTOR OF CREDENTIALING & ENROLL
- Phone
- (848) 326-8840
Specialties & Taxonomy Codes
| Specialty |
|---|
| Dentist - General Practice — General Practice |
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