Provider Demographics
NPI:1033926662
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:
Practice Address - Street 1:2029 LYNNHAVEN PKWY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-1474
Practice Address - Country:US
Practice Address - Phone:757-703-1923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC DENTAL CARE OF TIDEWATER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty