Provider Demographics
NPI:1063960706
Name:JENKINS, TIESHA GISELLE (HYGIENIST)
Entity type:Individual
Prefix:MRS
First Name:TIESHA
Middle Name:GISELLE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 PINE HILL CT LOT 15
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-5127
Mailing Address - Country:US
Mailing Address - Phone:843-731-4380
Mailing Address - Fax:
Practice Address - Street 1:4323 HILL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29207-6022
Practice Address - Country:US
Practice Address - Phone:843-731-4380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8255124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist