Provider Demographics
NPI:1114924933
Name:TIMOTHY R. HARBOLT, DMD
Entity Type:Organization
Organization Name:TIMOTHY R. HARBOLT, DMD
Other - Org Name:FAMILY DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARBOLT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-551-6349
Mailing Address - Street 1:4734 RIVER RD N
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4536
Mailing Address - Country:US
Mailing Address - Phone:503-463-4663
Mailing Address - Fax:503-463-4666
Practice Address - Street 1:4734 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4536
Practice Address - Country:US
Practice Address - Phone:503-463-4663
Practice Address - Fax:503-463-4666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD6816OtherSTATE LICENSE NUMBER