Provider Demographics
NPI:1760504443
Name:CASE, TIMOTHY GORDON (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:GORDON
Last Name:CASE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 HOLLY HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-2253
Mailing Address - Country:US
Mailing Address - Phone:314-351-5555
Mailing Address - Fax:314-351-5257
Practice Address - Street 1:4300 HOLLY HILLS BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-2253
Practice Address - Country:US
Practice Address - Phone:314-351-5555
Practice Address - Fax:314-351-5257
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO146381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice