Provider Demographics
NPI:1275837171
Name:TIMOTHY TIEN DDS PC
Entity Type:Organization
Organization Name:TIMOTHY TIEN DDS PC
Other - Org Name:BOULEVARD DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:QUOC
Authorized Official - Last Name:TIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-584-8975
Mailing Address - Street 1:3531 EL CAJON BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-1512
Mailing Address - Country:US
Mailing Address - Phone:619-584-8975
Mailing Address - Fax:619-584-0682
Practice Address - Street 1:3531 EL CAJON BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-1512
Practice Address - Country:US
Practice Address - Phone:619-584-8975
Practice Address - Fax:619-584-0682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA579261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ825739OtherARIZONA AHCCCS ID#