Provider Demographics
NPI:1609842061
Name:PIVONKA, TIMOTHY M (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:PIVONKA
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:PO BOX 1107
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441-1107
Mailing Address - Country:US
Mailing Address - Phone:785-238-4711
Mailing Address - Fax:785-238-4260
Practice Address - Street 1:361 GRANT AVE
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-4201
Practice Address - Country:US
Practice Address - Phone:785-238-4711
Practice Address - Fax:785-238-4260
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60329122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS117182OtherBLUE CROSS/BLUE SHIELD
KS0008976Medicaid