Provider Demographics
NPI:1598958548
Name:TIMMERMAN, CLINTON SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:SCOTT
Last Name:TIMMERMAN
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 1:807 S DOGWOOD CT
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-7564
Mailing Address - Country:US
Mailing Address - Phone:206-818-0769
Mailing Address - Fax:
Practice Address - Street 1:410 MACON AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3225
Practice Address - Country:US
Practice Address - Phone:719-276-0117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA579711223G0001X
WADE600462331223G0001X
IA085151223G0001X
CODEN.000107451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice