| Tidewater Llc | |
|
30320 Triangle Dr Charlotte Hall MD 20622-4109 | |
| (301) 359-1717 | |
| (301) 359-1719 |
| Full Name | Tidewater Llc |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 30320 Triangle Dr, Charlotte Hall, Maryland |
| Authorized Official Name and Position | Simone Wilson (DIRECTOR OF CREDENTIALING & ENROLL) |
| Authorized Official Contact | 8483268840 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Tidewater Llc 21534 Great Mills Rd Lexington Park MD 20653-1204 Ph: () - | Tidewater Llc 30320 Triangle Dr Charlotte Hall MD 20622-4109 Ph: (301) 359-1717 |
| NPI Number | 1144884560 |
|---|---|
| Provider Enumeration Date | 05/01/2019 |
| Last Update Date | 05/02/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1144884560 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | (* (Not Available)) | Primary |
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