Provider Demographics
NPI:1760741458
Name:WILSON, TIFFANY (DDS)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 DR DB TODD JR BLVD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-3501
Mailing Address - Country:US
Mailing Address - Phone:615-327-6210
Mailing Address - Fax:
Practice Address - Street 1:1005 DR DB TODD JR BLVD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37208-3501
Practice Address - Country:US
Practice Address - Phone:615-327-6210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031978122300000X
CA62605122300000X
TN10938122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist