Provider Demographics
NPI:1881791259
Name:MIDDAUGH, TIM (DMD)
Entity type:Individual
Prefix:MR
First Name:TIM
Middle Name:
Last Name:MIDDAUGH
Suffix:
Gender:M
Credentials:DMD
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 2080
Mailing Address - Street 2:331 E. JEWETT BLVD.
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-2080
Mailing Address - Country:US
Mailing Address - Phone:509-493-4546
Mailing Address - Fax:509-493-4435
Practice Address - Street 1:331 E. JEWETT BLVD.
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672-2080
Practice Address - Country:US
Practice Address - Phone:509-493-4546
Practice Address - Fax:509-493-4435
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE81631223G0001X
ORD70081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5033428Medicaid