Provider Demographics
NPI:1619909892
Name:TIEFENBACH, MARIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:
Last Name:TIEFENBACH
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 1:6200 SARATOGA BLVD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-3421
Mailing Address - Country:US
Mailing Address - Phone:361-992-9500
Mailing Address - Fax:361-992-1862
Practice Address - Street 1:3435 S ALAMEDA ST STE A
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1797
Practice Address - Country:US
Practice Address - Phone:361-853-0381
Practice Address - Fax:361-992-1862
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214541223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159673601Medicaid
TX159673601Medicaid