Provider Demographics
NPI:1891709465
Name:MOORE, TIMOTHY HAMMAN (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:HAMMAN
Last Name:MOORE
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 1:1199 GLENN AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-3231
Mailing Address - Country:US
Mailing Address - Phone:614-486-2521
Mailing Address - Fax:
Practice Address - Street 1:2508 BETHEL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2293
Practice Address - Country:US
Practice Address - Phone:614-459-5205
Practice Address - Fax:614-459-5942
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH176771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH186852OtherUNITED CONCORDIA