Healthcare Provider Details

I. General information

NPI: 1881815686
Provider Name (Legal Business Name): TIMOTHY MARK PENTECOST DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2453 BUHNE ST
EUREKA CA
95501-3206
US

IV. Provider business mailing address

2453 BUHNE ST
EUREKA CA
95501-3206
US

V. Phone/Fax

Practice location:
  • Phone: 707-443-7069
  • Fax: 707-443-9803
Mailing address:
  • Phone: 707-443-7069
  • Fax: 707-443-9803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberBP36106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: