Provider Demographics
NPI:1760664569
Name:REILLY, TIMOTHY PHILIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:PHILIP
Last Name:REILLY
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 1:6405 TELEGRAPH RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1716
Mailing Address - Country:US
Mailing Address - Phone:248-642-4484
Mailing Address - Fax:248-885-8704
Practice Address - Street 1:6405 TELEGRAPH RD
Practice Address - Street 2:SUITE G
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48301-1716
Practice Address - Country:US
Practice Address - Phone:248-642-4484
Practice Address - Fax:248-855-8704
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI16949122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist