Provider Demographics
NPI:1518073600
Name:WARREN, TIMOTHY MACK (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MACK
Last Name:WARREN
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 1:4701 ALTAMESA BLVD
Mailing Address - Street 2:SUITE #1D
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133
Mailing Address - Country:US
Mailing Address - Phone:817-292-8080
Mailing Address - Fax:817-370-7763
Practice Address - Street 1:4701 ALTAMESA BLVD
Practice Address - Street 2:SUITE #1D
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133
Practice Address - Country:US
Practice Address - Phone:817-292-8080
Practice Address - Fax:817-370-7763
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice