Provider Demographics
NPI:1699853051
Name:ITEN, TIMOTHY J (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:ITEN
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 1:1 MARION AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-7905
Mailing Address - Country:US
Mailing Address - Phone:419-522-5437
Mailing Address - Fax:
Practice Address - Street 1:1 MARION AVE STE 201
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-7905
Practice Address - Country:US
Practice Address - Phone:419-522-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH193051223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry