Provider Demographics
NPI:1114066727
Name:HANNON, TIMOTHY JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:HANNON
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 1:51 BRYNSTONE CT
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14228-3703
Mailing Address - Country:US
Mailing Address - Phone:716-691-7053
Mailing Address - Fax:
Practice Address - Street 1:39 DELAWARE RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14217-2742
Practice Address - Country:US
Practice Address - Phone:716-874-9981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0463181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02259061Medicaid