Provider Demographics
NPI:1295179745
Name:TIDWELL, VICTORIA LANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:LANE
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7885 NORMANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-6640
Mailing Address - Country:US
Mailing Address - Phone:904-783-1633
Mailing Address - Fax:
Practice Address - Street 1:12385 SORRENTO RD STE B1
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-8656
Practice Address - Country:US
Practice Address - Phone:850-492-7647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 20201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist