Provider Demographics
NPI:1407474729
Name:TIMMONS, BRYANT ADAMS (DDS)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:ADAMS
Last Name:TIMMONS
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 1:105 N WHITLEY DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2430
Mailing Address - Country:US
Mailing Address - Phone:208-452-6280
Mailing Address - Fax:208-452-4029
Practice Address - Street 1:105 N WHITLEY DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2430
Practice Address - Country:US
Practice Address - Phone:208-452-6280
Practice Address - Fax:208-452-4029
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID51761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice