Provider Demographics
NPI:1407803398
Name:TIDWELL, OTTO FREDERICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:OTTO
Middle Name:FREDERICK
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:19323 LIGHTHOUSE PLAZA BLVD
Mailing Address - Street 2:UNIT 4
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-6162
Mailing Address - Country:US
Mailing Address - Phone:215-880-9919
Mailing Address - Fax:215-557-8551
Practice Address - Street 1:19323 LIGHTHOUSE PLAZA BLVD
Practice Address - Street 2:UNIT 4
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-6162
Practice Address - Country:US
Practice Address - Phone:302-226-1606
Practice Address - Fax:302-226-1609
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PADS022622L1223S0112X
NJ22DIO14755001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0060881000OtherBLUE CROSS PROVIDER NUMBE
PA121367OtherUNITED CONCORDIA PROVIDER