Provider Demographics
NPI:1699811315
Name:SMITH, TIMOTHY E (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:E
Last Name:SMITH
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 1:1630 KENWOOD AVE
Mailing Address - Street 2:KENWOOD DENTAL
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811
Mailing Address - Country:US
Mailing Address - Phone:218-728-4288
Mailing Address - Fax:218-724-8624
Practice Address - Street 1:1630 KENWOOD AVE
Practice Address - Street 2:KENWOOD DENTAL
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811
Practice Address - Country:US
Practice Address - Phone:218-728-4288
Practice Address - Fax:218-724-8624
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN86111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice