Provider Demographics
NPI:1750471140
Name:TIMOTHY BENNETT DENTAL CORPORATION
Entity Type:Organization
Organization Name:TIMOTHY BENNETT DENTAL CORPORATION
Other - Org Name:WALERGA DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-725-4530
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-508-3600
Mailing Address - Fax:714-368-2092
Practice Address - Street 1:8008 WALERGA RD
Practice Address - Street 2:STE. 100
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843
Practice Address - Country:US
Practice Address - Phone:916-725-4530
Practice Address - Fax:916-725-4560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty