Provider Demographics
NPI:1699831453
Name:O'LEARY, TIMOTHY JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:O'LEARY
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 1:4292 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-4808
Mailing Address - Country:US
Mailing Address - Phone:585-663-3957
Mailing Address - Fax:
Practice Address - Street 1:4292 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-4808
Practice Address - Country:US
Practice Address - Phone:585-663-3957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0383701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7438OtherROCHESTER BLUE SHIELD ID
NY00843852Medicaid