Provider Demographics
NPI:1336149970
Name:DURKIN, TIMOTHY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:R
Last Name:DURKIN
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:PO BOX 19177
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96151-0177
Mailing Address - Country:US
Mailing Address - Phone:209-471-3140
Mailing Address - Fax:
Practice Address - Street 1:3443 LAKE TAHOE BLVD
Practice Address - Street 2:SUITE #B
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-8910
Practice Address - Country:US
Practice Address - Phone:530-544-3426
Practice Address - Fax:530-542-7710
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2015-12-15
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
CA298161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice