Organization
TIDEWATER LLC
Active
Parent organization
TIDEWATER, LLC
Organization subpart
Yes
Provider details
NPI number
Legal business name
TIDEWATER, LLC
Authorized official
SIMONE WILSON-ADELEKE (DIRECTOR OF CREDENTIALING & ENROLL)
(848) 326-8840
Entity
Organization
Contact information
Practice address
1720 CRAIN HWY S STE 103, GLEN BURNIE, MD 21061-5631
(410) 761-0095
Mailing address
21534 GREAT MILLS RD, LEXINGTON PARK, MD 20653-1204
(301) 862-3900
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
—
—
Other
Enumeration date
05/02/2023
Last updated
05/02/2023
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