Provider Demographics
NPI:1659488849
Name:O BRIEN, TIMOTHY JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:O BRIEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:TIMOTHY
Other - Middle Name:JAMES
Other - Last Name:O BRIEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:707 6TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54408
Mailing Address - Country:US
Mailing Address - Phone:715-627-4391
Mailing Address - Fax:715-627-4392
Practice Address - Street 1:707 6TH AVENUE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54408
Practice Address - Country:US
Practice Address - Phone:715-627-4391
Practice Address - Fax:715-627-4392
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001261-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist