Healthcare Provider Details

I. General information

NPI: 1144668989
Provider Name (Legal Business Name): TIMOTHY WILLIAM SURBER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 BROWNSTONE DR
INDIANAPOLIS IN
46220-5851
US

IV. Provider business mailing address

5701 BROWNSTONE DR
INDIANAPOLIS IN
46220-5851
US

V. Phone/Fax

Practice location:
  • Phone: 219-771-6926
  • Fax:
Mailing address:
  • Phone: 219-771-6926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12011990A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: