Provider Demographics
NPI:1891915112
Name:PEDIATRIC DENTAL CARE OF TIDEWATER PC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL CARE OF TIDEWATER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:TREY
Authorized Official - Last Name:WEIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-484-8262
Mailing Address - Street 1:5915 HIGH ST W
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-4505
Mailing Address - Country:US
Mailing Address - Phone:757-484-8262
Mailing Address - Fax:757-638-3632
Practice Address - Street 1:5915 HIGH STREET WEST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703
Practice Address - Country:US
Practice Address - Phone:757-484-8262
Practice Address - Fax:757-638-3632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014104961223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
249681OtherANTHEM
1702520OtherUNITED CONCORDIA