Provider Demographics
NPI:1689747966
Name:ROSER, TIMOTHY WAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:ROSER
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 1:1000 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-2402
Mailing Address - Country:US
Mailing Address - Phone:618-382-8300
Mailing Address - Fax:618-382-8322
Practice Address - Street 1:1000 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-2402
Practice Address - Country:US
Practice Address - Phone:618-382-8300
Practice Address - Fax:618-382-8322
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice