Organization
TIDEWATER LLC
Active
Parent organization
TIDEWATER, LLC
Organization subpart
Yes
Provider details
NPI number
Legal business name
TIDEWATER, LLC
Authorized official
SIMONE WILSON (DIRECTOR OF CREDENTIALING & ENROLL)
(848) 326-8840
Entity
Organization
Contact information
Practice address
30320 TRIANGLE DR, CHARLOTTE HALL, MD 20622-4109
(301) 359-1717
(301) 359-1719
Mailing address
21534 GREAT MILLS RD, LEXINGTON PARK, MD 20653-1204
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Enumeration date
05/01/2019
Last updated
05/02/2023
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