Provider Demographics
NPI:1124363924
Name:GILLUM, TIFFANY (DDS)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GILLUM
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 1:10750 BARKER CYPRESS RD
Mailing Address - Street 2:STE #111
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-2298
Mailing Address - Country:US
Mailing Address - Phone:281-213-8666
Mailing Address - Fax:281-256-2819
Practice Address - Street 1:103 N BRENTWOOD STE 400
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-7147
Practice Address - Country:US
Practice Address - Phone:936-639-4867
Practice Address - Fax:936-639-4868
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-05
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28293122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist