Healthcare Provider Details

I. General information

NPI: 1982010427
Provider Name (Legal Business Name): TIFFANY WU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5262 E BEVERLY BLVD
LOS ANGELES CA
90022-2002
US

IV. Provider business mailing address

406 E FAIRVIEW AVENUE
SAN GABRIEL CA
91776-2002
US

V. Phone/Fax

Practice location:
  • Phone: 323-887-0088
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number64331
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: