Provider Demographics
NPI:1073681029
Name:REILLY, TIMOTHY M (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:M
Last Name:REILLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5978 HARVEY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-9737
Mailing Address - Country:US
Mailing Address - Phone:231-799-0404
Mailing Address - Fax:231-799-0014
Practice Address - Street 1:5978 HARVEY ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-9737
Practice Address - Country:US
Practice Address - Phone:231-799-0404
Practice Address - Fax:231-799-0014
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI15138122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1929192Medicaid
MIJ801835OtherMICHIGAN BCBS DENTAL