Provider Demographics
NPI:1568996585
Name:TIDAL CREEK DENTAL LLC
Entity Type:Organization
Organization Name:TIDAL CREEK DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GAILLARDETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:603-321-9029
Mailing Address - Street 1:1127 QUEENSBOROUGH BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-5431
Mailing Address - Country:US
Mailing Address - Phone:603-321-9029
Mailing Address - Fax:
Practice Address - Street 1:1127 QUEENSBOROUGH BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5431
Practice Address - Country:US
Practice Address - Phone:603-321-9029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty