Provider Demographics
NPI:1508247206
Name:WHALEY, TIMOTHY (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:WHALEY
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 1:1019 S OSPREY AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-8432
Mailing Address - Country:US
Mailing Address - Phone:302-448-0336
Mailing Address - Fax:
Practice Address - Street 1:5947 FACTORY SHOPS BLVD
Practice Address - Street 2:
Practice Address - City:ELLENTON
Practice Address - State:FL
Practice Address - Zip Code:34222-4125
Practice Address - Country:US
Practice Address - Phone:941-479-7936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 21312122300000X
FL21312122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1508247206Medicaid