Provider Demographics
NPI:1598393183
Name:HAFFNER, TIMOTHY MICHAEL
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:HAFFNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S PRESTON ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1701
Mailing Address - Country:US
Mailing Address - Phone:502-852-3534
Mailing Address - Fax:
Practice Address - Street 1:87 ELM ST # 302
Practice Address - Street 2:
Practice Address - City:HOPKINTON
Practice Address - State:MA
Practice Address - Zip Code:01748-1638
Practice Address - Country:US
Practice Address - Phone:508-293-1446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN18589711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program