Healthcare Provider Details

I. General information

NPI: 1629138425
Provider Name (Legal Business Name): TIMOTHY P RAUSCH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 US HWY 61
NEW MADRID MO
63869
US

IV. Provider business mailing address

PO BOX 250 645 US HWY 61
NEW MADRID MO
63869
US

V. Phone/Fax

Practice location:
  • Phone: 573-748-2225
  • Fax: 573-748-5655
Mailing address:
  • Phone: 573-748-2225
  • Fax: 573-748-5655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE015440
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE-015440
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: