Healthcare Provider Details

I. General information

NPI: 1285653378
Provider Name (Legal Business Name): DIMITRY TIMOTHY PHILIPOVITCH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2813 COFFEE RD STE B2
MODESTO CA
95355-1755
US

IV. Provider business mailing address

3601 SPRINGBROOK ST
DALLAS TX
75205-4338
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-4884
  • Fax: 209-526-6133
Mailing address:
  • Phone: 415-519-7374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number40386
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number29435
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: