Provider Demographics
NPI:1619099066
Name:STRAIGHT, TIMOTHY MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MARK
Last Name:STRAIGHT
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 293
Mailing Address - Street 2:
Mailing Address - City:PORT AUSTIN
Mailing Address - State:MI
Mailing Address - Zip Code:48467-0293
Mailing Address - Country:US
Mailing Address - Phone:989-738-5681
Mailing Address - Fax:
Practice Address - Street 1:1405 CENTER AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6109
Practice Address - Country:US
Practice Address - Phone:989-893-4381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012718122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist