Healthcare Provider Details

I. General information

NPI: 1730678210
Provider Name (Legal Business Name): TIMOTHY WILLIAM DODD SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 NEWPORT BEACH BLVD
EAST MORICHES NY
11940-1566
US

IV. Provider business mailing address

10 NEWPORT BEACH BLVD
EAST MORICHES NY
11940-1566
US

V. Phone/Fax

Practice location:
  • Phone: 631-761-2504
  • Fax:
Mailing address:
  • Phone: 631-680-0728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number584536
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number584536
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: