Provider Demographics
NPI:1336300250
Name:SHIELDS, TIFFANY KELLY (DMD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:KELLY
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:LYNN
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3940 SAN JOSE PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4613
Mailing Address - Country:US
Mailing Address - Phone:904-731-0777
Mailing Address - Fax:904-731-0142
Practice Address - Street 1:3940 SAN JOSE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4613
Practice Address - Country:US
Practice Address - Phone:904-731-0777
Practice Address - Fax:904-731-0142
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN182761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice