Provider Demographics
NPI:1942550694
Name:HARBOLT, TIMOTHY RAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:RAY
Last Name:HARBOLT
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 1:6789 NW METGE AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-9355
Mailing Address - Country:US
Mailing Address - Phone:503-551-6349
Mailing Address - Fax:
Practice Address - Street 1:1174 MOLALLA AVE
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-3770
Practice Address - Country:US
Practice Address - Phone:503-646-6464
Practice Address - Fax:503-557-4677
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice