Provider Demographics
NPI:1720083645
Name:PRATT, TIMOTHY MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:PRATT
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 1:8108 PRIVATE ROAD 340
Mailing Address - Street 2:
Mailing Address - City:MILLERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44654-9158
Mailing Address - Country:US
Mailing Address - Phone:330-674-0847
Mailing Address - Fax:
Practice Address - Street 1:150 WEST FRONT ST.
Practice Address - Street 2:
Practice Address - City:KILLBUCK
Practice Address - State:OH
Practice Address - Zip Code:44637-0459
Practice Address - Country:US
Practice Address - Phone:330-276-3705
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH176851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0576612Medicaid