Provider Demographics
NPI:1457739666
Name:STICE, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:STICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 FOWLER AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-3001
Mailing Address - Country:US
Mailing Address - Phone:559-579-5513
Mailing Address - Fax:
Practice Address - Street 1:6323 N FRESNO ST
Practice Address - Street 2:101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5282
Practice Address - Country:US
Practice Address - Phone:559-439-2607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81382126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA81382OtherDENTAL ASSISTANT