Provider Demographics
NPI:1609889864
Name:MITCHENER, TIMOTHY ALLEN (DMD, MPH)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:MITCHENER
Suffix:
Gender:M
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5158 BLACK HAWK RD
Mailing Address - Street 2:
Mailing Address - City:GUNPOWDER
Mailing Address - State:MD
Mailing Address - Zip Code:21010-5403
Mailing Address - Country:US
Mailing Address - Phone:410-436-5001
Mailing Address - Fax:
Practice Address - Street 1:5158 BLACK HAWK RD
Practice Address - Street 2:
Practice Address - City:GUNPOWDER
Practice Address - State:MD
Practice Address - Zip Code:21010-5403
Practice Address - Country:US
Practice Address - Phone:410-436-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000048751223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health