Provider Demographics
NPI:1801520796
Name:TIFFANY SRECA DMD PC
Entity type:Organization
Organization Name:TIFFANY SRECA DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:SRECA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-464-8853
Mailing Address - Street 1:25 COLDBROOK RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05363-9624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 COLDBROOK RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:VT
Practice Address - Zip Code:05363-9624
Practice Address - Country:US
Practice Address - Phone:802-464-8853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental