Provider Demographics
NPI:1083862858
Name:YOUNG, TIFFANY PETULIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:PETULIA
Last Name:YOUNG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 W COLORADO ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-3097
Mailing Address - Country:US
Mailing Address - Phone:818-244-4063
Mailing Address - Fax:
Practice Address - Street 1:412 W COLORADO ST
Practice Address - Street 2:SUITE C
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-3097
Practice Address - Country:US
Practice Address - Phone:818-244-4063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA576011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice