Provider Demographics
NPI:1558421107
Name:WILSON, TIFFANIE S (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANIE
Middle Name:S
Last Name:WILSON
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 1:12801 EDGEMERE BLVD # B
Mailing Address - Street 2:STE 112
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-9500
Mailing Address - Country:US
Mailing Address - Phone:915-493-6310
Mailing Address - Fax:
Practice Address - Street 1:12801 EDGEMERE BLVD # B
Practice Address - Street 2:STE 112
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-9500
Practice Address - Country:US
Practice Address - Phone:915-493-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24464122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist