Provider Demographics
NPI:1952687360
Name:SOUTHERN DELAWARE ASSOCIATES OF DENTAL SPECIALITIES
Entity Type:Organization
Organization Name:SOUTHERN DELAWARE ASSOCIATES OF DENTAL SPECIALITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:215-880-9919
Mailing Address - Street 1:19323 LIGHTHOUSE PLAZA BLVD
Mailing Address - Street 2:UNIT 4
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-6162
Mailing Address - Country:US
Mailing Address - Phone:215-880-9919
Mailing Address - Fax:
Practice Address - Street 1:19323 LIGHTHOUSE PLAZA BLVD
Practice Address - Street 2:UNIT 4
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-6162
Practice Address - Country:US
Practice Address - Phone:215-880-9919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-30
Last Update Date:2011-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery