Provider Demographics
NPI:1831748417
Name:TAVARES, TIFFANY (DDS, DMSC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:TAVARES
Suffix:
Gender:F
Credentials:DDS, DMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7703 FLOYD CURL DR # 7914
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3901
Mailing Address - Country:US
Mailing Address - Phone:210-450-3088
Mailing Address - Fax:
Practice Address - Street 1:8210 FLOYD CURL DR # 8109
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3923
Practice Address - Country:US
Practice Address - Phone:210-450-3230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019034508125Q00000X
TX36888125Q00000X, 1223S0112X, 125Q00000X
TX3688125Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125Q00000XDental ProvidersDentistOral Medicine
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery