Provider Demographics
NPI:1053316463
Name:SUPAN, TIMOTHY D (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:D
Last Name:SUPAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 197
Mailing Address - Street 2:
Mailing Address - City:GRIDLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61744-0197
Mailing Address - Country:US
Mailing Address - Phone:309-747-2213
Mailing Address - Fax:309-747-3989
Practice Address - Street 1:205 E GRIDLEY RD
Practice Address - Street 2:
Practice Address - City:GRIDLEY
Practice Address - State:IL
Practice Address - Zip Code:61744-8733
Practice Address - Country:US
Practice Address - Phone:309-747-2213
Practice Address - Fax:309-747-3989
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice