Provider Demographics
NPI:1205866365
Name:EICKMANN, TIMM H (DDS)
Entity Type:Individual
Prefix:
First Name:TIMM
Middle Name:H
Last Name:EICKMANN
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 1:1515 DIAMOND WALL DR
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-8449
Mailing Address - Country:US
Mailing Address - Phone:970-460-7226
Mailing Address - Fax:970-460-7226
Practice Address - Street 1:1515 DIAMOND WALL DR
Practice Address - Street 2:
Practice Address - City:BERTHOUD
Practice Address - State:CO
Practice Address - Zip Code:80513-8449
Practice Address - Country:US
Practice Address - Phone:970-460-7226
Practice Address - Fax:970-460-7226
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO107301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT11-1280Medicaid