Healthcare Provider Details

I. General information

NPI: 1609869080
Provider Name (Legal Business Name): TIMOTHY A. MAGNUSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 MC KENZIE AVE
ARNOLD CA
95223
US

IV. Provider business mailing address

PO BOX 540
ARNOLD CA
95223-0540
US

V. Phone/Fax

Practice location:
  • Phone: 209-795-4426
  • Fax: 209-795-2659
Mailing address:
  • Phone: 209-795-4426
  • Fax: 209-795-2659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number23739
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: