Provider Demographics
NPI:1043600604
Name:TIMBERLANE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:TIMBERLANE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTION
Authorized Official - Prefix:MISS
Authorized Official - First Name:MISSY
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:DEGOLYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-746-9111
Mailing Address - Street 1:1972 N FUTURE TER
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-9341
Mailing Address - Country:US
Mailing Address - Phone:352-746-9111
Mailing Address - Fax:352-746-7180
Practice Address - Street 1:1972 N FUTURE TER
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-9341
Practice Address - Country:US
Practice Address - Phone:352-746-9111
Practice Address - Fax:352-746-7180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5932465191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty