Provider Demographics
NPI:1164649331
Name:KITZMILLER, TIMOTHY J
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:KITZMILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5722 SIGNAL HILL COURT
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150
Mailing Address - Country:US
Mailing Address - Phone:513-248-8848
Mailing Address - Fax:513-248-9094
Practice Address - Street 1:5722 SIGNAL HILL COURT
Practice Address - Street 2:SUITE A
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150
Practice Address - Country:US
Practice Address - Phone:513-248-8848
Practice Address - Fax:513-248-9094
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17936122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6689070001Medicare NSC