MEDICARE: TIFFANY KELLY SHIELDS DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN18276	FL

General Provider Information

NPI Number	:	1336300250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY KELLY SHIELDS DMD

Provider Business Mailing Address
First Line	:	3940 SAN JOSE PARK DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-4613
Country	:	US
Telephone Number	:	904-731-0777
Fax Number	:	904-731-0142

Provider Business Practice Location Address
First Line	:	3940 SAN JOSE PARK DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-4613
Country	:	US
Telephone Number	:	904-731-0777
Fax Number	:	904-731-0142

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2008
Last Update Date	:	10/08/2010

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