MEDICARE: TIFFANY MO 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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1568393353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY MO DMD

Provider Business Mailing Address
First Line	:	851 PARK DR STE 101
Second Line	:
City	:	LAKE GENEVA
State	:	WI
Zip	:	53147-4586
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	851 PARK DR STE 101
Second Line	:
City	:	LAKE GENEVA
State	:	WI
Zip	:	53147-4586
Country	:	US
Telephone Number	:	262-248-4991
Fax Number	:

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

Provider Enumeration Date	:	05/28/2026
Last Update Date	:	05/28/2026

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