Provider Demographics
NPI:1760604177
Name:PICKENS, TIMOTHY NED (DDS,MS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:NED
Last Name:PICKENS
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3183 THISTLE CT
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-9576
Mailing Address - Country:US
Mailing Address - Phone:734-904-7602
Mailing Address - Fax:734-429-5774
Practice Address - Street 1:3183 THISTLE CT
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-9576
Practice Address - Country:US
Practice Address - Phone:734-904-7602
Practice Address - Fax:734-429-5774
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010100191223S0112X
AZ22111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery