Provider Demographics
NPI:1508240235
Name:HALL, TIMOTHY MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:HALL
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 1:10504 S CLEARVIEW LN
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-2062
Mailing Address - Country:US
Mailing Address - Phone:317-903-0245
Mailing Address - Fax:
Practice Address - Street 1:1301 N EPHRATA AVE
Practice Address - Street 2:
Practice Address - City:CONNELL
Practice Address - State:WA
Practice Address - Zip Code:99326-9601
Practice Address - Country:US
Practice Address - Phone:509-543-5978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE610694831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice