NPIMap

Organization Active NPI

Tidewater LLC

  • General Practice Dentistry
  • Charlotte Hall, MD
National Provider Identifier
1144884560
Registry record updated May 2, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
TIDEWATER LLC
Practice address
30320 Triangle Dr
Charlotte Hall, MD 20622-4109
Phone
(301) 359-1717
Fax
(301) 359-1719
NPI assigned
May 1, 2019
Last updated
May 2, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
TIDEWATER, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 2, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Simone Wilson
Title
Director of Credentialing & Enroll
Phone
(848) 326-8840

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X Primary

Addresses

Primary practice location

30320 Triangle Dr
Charlotte Hall, MD 20622-4109

Mailing address

21534 Great Mills Rd
Lexington Park, MD 20653-1204

National Provider Directory

National Provider Directory
Tax ID family
Tidewater LLC9 organizations share this tax ID, including this one
Part of
Tidewater LLC

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

Locations

30320 Triangle Dr
Charlotte Hall, MD 20622
Phone (301) 359-1717

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1556668800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682985600000",
    "number": "1144884560",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21534 GREAT MILLS RD",
            "city": "LEXINGTON PARK",
            "state": "MD",
            "postal_code": "206531204"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "30320 TRIANGLE DR",
            "city": "CHARLOTTE HALL",
            "state": "MD",
            "postal_code": "206224109",
            "telephone_number": "301-359-1717",
            "fax_number": "301-359-1719"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "TIDEWATER, LLC",
        "enumeration_date": "2019-05-01",
        "last_updated": "2023-05-02",
        "certification_date": "2023-05-02",
        "status": "A",
        "authorized_official_last_name": "WILSON",
        "authorized_official_first_name": "SIMONE",
        "authorized_official_title_or_position": "DIRECTOR OF CREDENTIALING & ENROLL",
        "authorized_official_telephone_number": "848-326-8840"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Charlotte Hall, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 2, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.