Provider Demographics
NPI:1629138425
Name:RAUSCH, TIMOTHY P (DMD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:RAUSCH
Suffix:
Gender:M
Credentials:DMD
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 250
Mailing Address - Street 2:645 US HWY 61
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869
Mailing Address - Country:US
Mailing Address - Phone:573-748-2225
Mailing Address - Fax:573-748-5655
Practice Address - Street 1:645 US HWY 61
Practice Address - Street 2:
Practice Address - City:NEW MADRID
Practice Address - State:MO
Practice Address - Zip Code:63869
Practice Address - Country:US
Practice Address - Phone:573-748-2225
Practice Address - Fax:573-748-5655
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE015440122300000X
MODE-015440122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO403746407Medicaid