Provider Demographics
NPI:1245328061
Name:LAVELLE, TIMOTHY COLIN (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:COLIN
Last Name:LAVELLE
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 1:207 N COLUMBUS ROAD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1335
Mailing Address - Country:US
Mailing Address - Phone:740-593-8530
Mailing Address - Fax:740-594-2215
Practice Address - Street 1:207 N COLUMBUS RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1335
Practice Address - Country:US
Practice Address - Phone:740-593-8530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17938122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2232113Medicaid