Provider Demographics
NPI:1245880590
Name:MCCAFFRIE, TINA RENAE (RDH)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:RENAE
Last Name:MCCAFFRIE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MISS
Other - First Name:TINA
Other - Middle Name:RENAE
Other - Last Name:GANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8828 JAYDEN LN NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-8200
Mailing Address - Country:US
Mailing Address - Phone:706-615-6670
Mailing Address - Fax:
Practice Address - Street 1:8828 JAYDEN LN NE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-8200
Practice Address - Country:US
Practice Address - Phone:706-615-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10829124Q00000X
GA7892124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist