Provider Demographics
NPI:1619054186
Name:MERRY, TIMOTHY JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:MERRY
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:W147N9887 RIMROCK ROAD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095
Practice Address - Country:US
Practice Address - Phone:262-338-0022
Practice Address - Fax:262-338-7982
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3135122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33489400Medicaid
BM3456907OtherDEA