MEDICARE: MS. TIFFANY LEANN ELSEY DENTAL ASSISTANT

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	126800000X	Dental Assistant

General Provider Information

NPI Number	:	1710490511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TIFFANY LEANN ELSEY DENTAL ASSISTANT

Provider Business Mailing Address
First Line	:	4655 OMAHA BEACH ST
Second Line	:
City	:	FORT IRWIN
State	:	CA
Zip	:	92310-1914
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4655 OMAHA BEACH ST
Second Line	:
City	:	FORT IRWIN
State	:	CA
Zip	:	92310-1914
Country	:	US
Telephone Number	:	843-743-3520
Fax Number	:

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

Provider Enumeration Date	:	11/15/2017
Last Update Date	:	02/13/2019

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