Provider Demographics
NPI:1457756884
Name:TIDEWATER FAMILY DENTISTRY
Entity Type:Organization
Organization Name:TIDEWATER FAMILY DENTISTRY
Other - Org Name:A DIVISION OF ATLANTIC DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-877-6787
Mailing Address - Street 1:559 DENBIGH BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-4215
Mailing Address - Country:US
Mailing Address - Phone:757-877-6787
Mailing Address - Fax:757-872-7208
Practice Address - Street 1:559 DENBIGH BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-4215
Practice Address - Country:US
Practice Address - Phone:757-877-6787
Practice Address - Fax:757-872-7208
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTIC DENTAL CARE, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014111101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty