Provider Demographics
NPI:1629291364
Name:HOLMES, TIMOTHY WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:HOLMES
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 1:100 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:MO
Mailing Address - Zip Code:63957-1563
Mailing Address - Country:US
Mailing Address - Phone:573-223-4513
Mailing Address - Fax:
Practice Address - Street 1:100 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:MO
Practice Address - Zip Code:63957-1563
Practice Address - Country:US
Practice Address - Phone:573-223-4513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO0150391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice