Provider Demographics
NPI:1740404201
Name:JUNGBLUT, TIMOTHY M (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:M
Last Name:JUNGBLUT
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 1:3907 S WESTNEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-3187
Mailing Address - Country:US
Mailing Address - Phone:269-345-8893
Mailing Address - Fax:269-492-1710
Practice Address - Street 1:3907 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-3187
Practice Address - Country:US
Practice Address - Phone:269-345-8893
Practice Address - Fax:269-492-1710
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010161151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901016115OtherSTATE LICENSE #
MI796159OtherUNITED CONCORDIA PROVIDER
MIBJ3311901OtherDEA #
1013074095Medicare UPIN
MI3273324Medicare ID - Type UnspecifiedSTATE MEDICAID #