Provider Demographics
NPI:1538104088
Name:KOOB, TIMOTHY J (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:KOOB
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 1:3146 WAUCHEETA TRL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-5952
Mailing Address - Country:US
Mailing Address - Phone:608-222-8093
Mailing Address - Fax:
Practice Address - Street 1:5801 RESEARCH PARK BLVD
Practice Address - Street 2:STE 110
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-6002
Practice Address - Country:US
Practice Address - Phone:608-274-0770
Practice Address - Fax:608-274-9224
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51091223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12127OtherDEAN HEALTH PLAN
WI33754500Medicaid
WI33754500Medicaid