Provider Demographics
NPI:1730475229
Name:TIDWELL, SCHAVEZ LABANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCHAVEZ
Middle Name:LABANE
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 2ND AVE
Mailing Address - Street 2:SUITE 504B
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3360
Mailing Address - Country:US
Mailing Address - Phone:301-565-5277
Mailing Address - Fax:301-565-0048
Practice Address - Street 1:8609 2ND AVE
Practice Address - Street 2:SUITE 504B
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3360
Practice Address - Country:US
Practice Address - Phone:301-565-5277
Practice Address - Fax:301-565-0048
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD92091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD09209OtherDENTIST LICENSE