Provider Demographics
NPI:1952567661
Name:TILTS, DAWN O (DDS)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:O
Last Name:TILTS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:M
Other - Last Name:OSOSKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3505 W LEAD ROPE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-2302
Mailing Address - Country:US
Mailing Address - Phone:928-525-6200
Mailing Address - Fax:928-213-9665
Practice Address - Street 1:518 N BEAVER ST
Practice Address - Street 2:SUITE A
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3020
Practice Address - Country:US
Practice Address - Phone:928-774-4705
Practice Address - Fax:928-213-9665
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7618122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ410898Medicaid