Provider Demographics
NPI:1750927232
Name:DAOUST, TIMBERLY SUE (RDH)
Entity type:Individual
Prefix:
First Name:TIMBERLY
Middle Name:SUE
Last Name:DAOUST
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4774 BAHAMA LN
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-9045
Mailing Address - Country:US
Mailing Address - Phone:269-271-2291
Mailing Address - Fax:
Practice Address - Street 1:302 S FRONT ST STE A
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-1750
Practice Address - Country:US
Practice Address - Phone:269-782-0064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2902013577124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2902013577OtherDENTAL HYGIENE LICENSE