NPIMap

Organization Active NPI

Tidewater LLC

  • Dentist
  • Glen Burnie, MD
National Provider Identifier
1760171060
Registry record updated May 2, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
Legal business name
TIDEWATER LLC
Practice address
1720 Crain Hwy S Ste 103
Glen Burnie, MD 21061-5631
Phone
(410) 761-0095
NPI assigned
May 2, 2023
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-Adeleke
Title
Director of Credentialing & Enroll
Phone
(848) 326-8840

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X Primary

Addresses

Primary practice location

1720 Crain Hwy S Ste 103
Glen Burnie, MD 21061-5631

Mailing address

21534 Great Mills Rd
Lexington Park, MD 20653-1204
Phone (301) 862-3900

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.

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": "1682985600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682985600000",
    "number": "1760171060",
    "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",
            "telephone_number": "301-862-3900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1720 CRAIN HWY S STE 103",
            "city": "GLEN BURNIE",
            "state": "MD",
            "postal_code": "210615631",
            "telephone_number": "410-761-0095"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "TIDEWATER, LLC",
        "enumeration_date": "2023-05-02",
        "last_updated": "2023-05-02",
        "certification_date": "2023-05-02",
        "status": "A",
        "authorized_official_last_name": "WILSON-ADELEKE",
        "authorized_official_first_name": "SIMONE",
        "authorized_official_title_or_position": "DIRECTOR OF CREDENTIALING & ENROLL",
        "authorized_official_telephone_number": "848-326-8840"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Glen Burnie, 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.