Healthcare Provider Details

I. General information

NPI: 1801298682
Provider Name (Legal Business Name): TIFFANIE CAMDEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8546 STONE MOUNTAIN CT
PEVELY MO
63070-1343
US

IV. Provider business mailing address

8546 STONE MOUNTAIN CT
PEVELY MO
63070-1343
US

V. Phone/Fax

Practice location:
  • Phone: 314-600-8263
  • Fax:
Mailing address:
  • Phone: 314-600-8263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2010040435
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020.013509
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: