Provider Demographics
NPI:1104838077
Name:LETHIN, TIMOTHY MICHAEL
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:LETHIN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:TIMOTHY
Other - Middle Name:MICHAEL
Other - Last Name:LETHIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2601 BONIFACE PKWY
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-3106
Mailing Address - Country:US
Mailing Address - Phone:907-337-9474
Mailing Address - Fax:907-337-9476
Practice Address - Street 1:2601 BONIFACE PKWY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-3106
Practice Address - Country:US
Practice Address - Phone:907-337-9474
Practice Address - Fax:907-337-9476
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1622826OtherUCCI
AKDD6052Medicaid