Provider Demographics
NPI:1366654030
Name:WILEY, TIMOTHY D (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:D
Last Name:WILEY
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 1:403 HACKETT PIKE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-9386
Mailing Address - Country:US
Mailing Address - Phone:859-624-0419
Mailing Address - Fax:
Practice Address - Street 1:1001 GIBSON BAY DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475
Practice Address - Country:US
Practice Address - Phone:859-625-0204
Practice Address - Fax:859-625-5223
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY62391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice