Provider Demographics
NPI:1255450870
Name:GLOMB, TIMOTHY
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:GLOMB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 ENTERPRISE RD
Mailing Address - Street 2:STE. 102
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-2753
Mailing Address - Country:US
Mailing Address - Phone:386-668-7776
Mailing Address - Fax:
Practice Address - Street 1:2808 ENTERPRISE RD
Practice Address - Street 2:STE. 102
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-2753
Practice Address - Country:US
Practice Address - Phone:386-668-7776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00134371223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry