Provider Demographics
NPI:1275671208
Name:CRISP, TIMOTHY F (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:F
Last Name:CRISP
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CANARY LN
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-1645
Mailing Address - Country:US
Mailing Address - Phone:859-744-7031
Mailing Address - Fax:859-744-9175
Practice Address - Street 1:11 CANARY LN
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1645
Practice Address - Country:US
Practice Address - Phone:859-744-7031
Practice Address - Fax:859-744-9175
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY63591223P0221X, 122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60063591Medicaid