Provider Demographics
NPI:1316540826
Name:TIFFANY GOLDWYN DMD PC
Entity Type:Organization
Organization Name:TIFFANY GOLDWYN DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDWYN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-244-8112
Mailing Address - Street 1:1616 SW SUNSET BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2641
Mailing Address - Country:US
Mailing Address - Phone:503-244-8112
Mailing Address - Fax:
Practice Address - Street 1:1616 SW SUNSET BLVD STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2641
Practice Address - Country:US
Practice Address - Phone:503-244-8112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty