Provider Demographics
NPI:1134206618
Name:PLISKE, TIMOTHY A (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:A
Last Name:PLISKE
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 1:2911 E COVENANTER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6320
Mailing Address - Country:US
Mailing Address - Phone:812-333-2614
Mailing Address - Fax:812-333-4594
Practice Address - Street 1:2911 E COVENANTER DR
Practice Address - Street 2:SUITE B
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6320
Practice Address - Country:US
Practice Address - Phone:812-333-2614
Practice Address - Fax:812-333-4594
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120095821223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN194860BMedicare ID - Type Unspecified
INU66437Medicare UPIN