Basic Information
| Provider Information | |||||||||
| NPI: | 1528583317 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENDT | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | JANELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 W LOSEY ST BLDG 1535 | ||||||||
| Address2: | |||||||||
| City: | SCOTT AFB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622255250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182569355 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 310 W LOSEY ST BLDG 1535 | ||||||||
| Address2: | |||||||||
| City: | SCOTT AFB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622255250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182569355 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2017 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 016.0132658 | VT | N | Dental Providers | Dentist | General Practice | 1223P0700X | 016.0132658 | VT | Y | Dental Providers | Dentist | Prosthodontics |
No ID Information.