Provider Demographics
NPI:1619507019
Name:TIDELANDS DENTAL ON GLENNS BAY LLC
Entity Type:Organization
Organization Name:TIDELANDS DENTAL ON GLENNS BAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-531-1001
Mailing Address - Street 1:3577 MARION LN
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-6012
Mailing Address - Country:US
Mailing Address - Phone:603-531-1001
Mailing Address - Fax:
Practice Address - Street 1:1625 GLENNS BAY RD
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-4836
Practice Address - Country:US
Practice Address - Phone:843-650-4500
Practice Address - Fax:843-650-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty