Basic Information
| Provider Information | |||||||||
| NPI: | 1518245331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PALMER | ||||||||
| FirstName: | TYFFANI | ||||||||
| MiddleName: | TYNNEIL | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 PAPPAS ST | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780411705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567958100 | ||||||||
| FaxNumber: | 9567186294 | ||||||||
| Practice Location | |||||||||
| Address1: | 7451 N BEACH ST STE 140 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761375160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178477001 | ||||||||
| FaxNumber: | 8178477009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2011 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 27199 | TX | N | Dental Providers | Dentist | 1223P0221X | 27199 | TX | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 27199 | 01 | TX | TEXAS DENTAL LICENSE | OTHER |