| Doctor Name: | DR. OTTO FREDERICK TIDWELL |
| NPI Number: | 1407803398 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.D.S. |
| License Number: | 22DIO1475500 |
| Business Practice Address: | 19323 Lighthouse Plaza Blvd Unit 4 Rehoboth Beach, DE - 199716162 |
| Business Phone Number: | 3022261606 |
| Business Fax Number: | 3022261609 |
| Mailing Address: | 19323 Lighthouse Plaza Blvd, Unit 4 REHOBOTH BEACH |
| State: | DE |
| Postal Code: | 199716162 |
| Phone Number: | 2158809919 |
| Fax Number: | 2155578551 |
| NPI Enumeration Date: | 05/27/2006 |
| NPI Last Update Date: | 01/14/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1223S0112X |
| License Number: | 22DIO1475500 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | NJ |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Dentist |
| Taxonomy Specialization: | Oral and Maxillofacial Surgery |
| Taxonomy Definition: | The specialty of dentistry which includes the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region. |