Provider Demographics
NPI:1407075377
Name:DUDLEY, TIMOTHY WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WILLIAM
Last Name:DUDLEY
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 1:4030 S MERIDIAN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-3889
Mailing Address - Country:US
Mailing Address - Phone:317-786-9501
Mailing Address - Fax:317-786-9403
Practice Address - Street 1:4030 S MERIDIAN ST
Practice Address - Street 2:SUITE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46217-3889
Practice Address - Country:US
Practice Address - Phone:317-786-9501
Practice Address - Fax:317-786-9403
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008850A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice