Provider Demographics
NPI:1235624081
Name:WADE, TIFFANY ELAINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:ELAINE
Last Name:WADE
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 1:41843 VIA AREGIO
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-1750
Mailing Address - Country:US
Mailing Address - Phone:760-567-7873
Mailing Address - Fax:
Practice Address - Street 1:146 S BROADWAY
Practice Address - Street 2:
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-2502
Practice Address - Country:US
Practice Address - Phone:760-567-7873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1026221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice