Provider Demographics
NPI:1396835450
Name:GOLDWYN, TIFFANY MICHELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:MICHELLE
Last Name:GOLDWYN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 SW SUNSET BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2641
Mailing Address - Country:US
Mailing Address - Phone:503-421-3040
Mailing Address - Fax:
Practice Address - Street 1:1616 SW SUNSET BLVD
Practice Address - Street 2:SUITE B
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:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD81451223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist