Provider Demographics
NPI:1003259797
Name:THEISEN, TIMOTHY MCMICHAEL (DMD)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MCMICHAEL
Last Name:THEISEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:TIMOTHY
Other - Middle Name:MCMICHAEL
Other - Last Name:THEISEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:4330 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-1443
Mailing Address - Country:US
Mailing Address - Phone:814-315-6209
Mailing Address - Fax:814-315-6303
Practice Address - Street 1:4330 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-1443
Practice Address - Country:US
Practice Address - Phone:814-315-6209
Practice Address - Fax:814-315-6303
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0384611223G0001X, 1223E0200X, 1223P0221X, 1223P0700X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No1223E0200XDental ProvidersDentistEndodontics
No1223P0221XDental ProvidersDentistPediatric Dentistry
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY056582OtherNYS LICENSE