Provider Demographics
NPI:1275789950
Name:TIDEWATER DENTAL CENTER, PLLC
Entity Type:Organization
Organization Name:TIDEWATER DENTAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-622-4245
Mailing Address - Street 1:425 W 20TH ST
Mailing Address - Street 2:3
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-2128
Mailing Address - Country:US
Mailing Address - Phone:757-622-4245
Mailing Address - Fax:757-622-3722
Practice Address - Street 1:425 W 20TH ST
Practice Address - Street 2:3
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-2128
Practice Address - Country:US
Practice Address - Phone:757-622-4245
Practice Address - Fax:757-622-3722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014112611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty