Provider Demographics
NPI:1225776842
Name:ELMALEM, TIFANY SHIREL
Entity Type:Individual
Prefix:
First Name:TIFANY
Middle Name:SHIREL
Last Name:ELMALEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 RIVERSIDE BLVD APT 8A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10069-1006
Mailing Address - Country:US
Mailing Address - Phone:347-843-5517
Mailing Address - Fax:
Practice Address - Street 1:860 5TH AVE # 1HJ
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-5856
Practice Address - Country:US
Practice Address - Phone:347-843-5517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0634411223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program