Provider Demographics
NPI:1982006888
Name:TIDEWATER DENTAL SOLOMONS ISLAND, LLC
Entity type:Organization
Organization Name:TIDEWATER DENTAL SOLOMONS ISLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-862-3900
Mailing Address - Street 1:21534 GREAT MILLS RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-1204
Mailing Address - Country:US
Mailing Address - Phone:301-862-3900
Mailing Address - Fax:
Practice Address - Street 1:14532 SOLOMONS ISLAND ROAD
Practice Address - Street 2:
Practice Address - City:SOLOMONS ISLAND
Practice Address - State:MD
Practice Address - Zip Code:20688
Practice Address - Country:US
Practice Address - Phone:301-862-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD64661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty