Individual
DR. OTTO FREDERICK TIDWELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Contact information
Practice address
19323 LIGHTHOUSE PLAZA BLVD, UNIT 4, REHOBOTH BEACH, DE 19971-6162
(302) 226-1606
(302) 226-1609
Mailing address
19323 LIGHTHOUSE PLAZA BLVD, UNIT 4, REHOBOTH BEACH, DE 19971-6162
(215) 880-9919
(215) 557-8551
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
22DIO1475500
NJ
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
DS022622L
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0060881000
BLUE CROSS PROVIDER NUMBE
PA
01
—
121367
UNITED CONCORDIA PROVIDER
PA
Enumeration date
05/27/2006
Last updated
01/14/2014
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