Provider Demographics
NPI:1780045112
Name:CALLAHAN, TIMOTHY BRADLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:BRADLEY
Last Name:CALLAHAN
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 1:3400 PAXTON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-4246
Mailing Address - Country:US
Mailing Address - Phone:704-906-3495
Mailing Address - Fax:
Practice Address - Street 1:2435 PLANTATION CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5148
Practice Address - Country:US
Practice Address - Phone:704-847-7426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-12
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC106741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty