Healthcare Provider Details

I. General information

NPI: 1104155647
Provider Name (Legal Business Name): TIFFANY ROSE GORR D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2009
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 W BRAKER LN
AUSTIN TX
78758-3801
US

IV. Provider business mailing address

2115 KRAMER LN SUITE 100
AUSTIN TX
78758-4013
US

V. Phone/Fax

Practice location:
  • Phone: 512-978-9880
  • Fax: 512-279-2556
Mailing address:
  • Phone: 512-978-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number58986
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number31822
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: