Provider Demographics
NPI:1154842516
Name:GANSORE, TIMOTHEE
Entity Type:Individual
Prefix:DR
First Name:TIMOTHEE
Middle Name:
Last Name:GANSORE
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:TIMOTHEE
Other - Middle Name:
Other - Last Name:GANSORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1138 MAIN ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-2582
Mailing Address - Country:US
Mailing Address - Phone:423-201-9917
Mailing Address - Fax:423-377-1069
Practice Address - Street 1:1138 MAIN ST UNIT C
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-2582
Practice Address - Country:US
Practice Address - Phone:423-201-9917
Practice Address - Fax:423-377-1069
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN105911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice