Provider Demographics
NPI:1144884560
Name:TIDEWATER LLC
Entity type:Organization
Organization Name:TIDEWATER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING & ENROLL
Authorized Official - Prefix:
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:848-326-8840
Mailing Address - Street 1:21534 GREAT MILLS RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-1204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30320 TRIANGLE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE HALL
Practice Address - State:MD
Practice Address - Zip Code:20622-4109
Practice Address - Country:US
Practice Address - Phone:301-359-1717
Practice Address - Fax:301-359-1719
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIDEWATER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-01
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty