Provider Demographics
NPI:1003568072
Name:TIDAL SMILES PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:TIDAL SMILES PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:LUKE
Authorized Official - Last Name:WINTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-327-6061
Mailing Address - Street 1:816 EVELYN WAY
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-2488
Mailing Address - Country:US
Mailing Address - Phone:540-327-6061
Mailing Address - Fax:
Practice Address - Street 1:1755 CITY CENTER BLVD UNIT B-2
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-8938
Practice Address - Country:US
Practice Address - Phone:252-251-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIDAL SMILES PEDIATRIC DENTISTRY, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental