Provider Demographics
NPI:1548782873
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:PEDIATRIC DENTIST, 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:757-482-4777
Mailing Address - Street 1:350 JOHNSTOWN RD STE C
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-5365
Mailing Address - Country:US
Mailing Address - Phone:757-482-4777
Mailing Address - Fax:
Practice Address - Street 1:350 JOHNSTOWN RD STE C
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-5365
Practice Address - Country:US
Practice Address - Phone:757-482-4777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty