Healthcare Provider Details

I. General information

NPI: 1467008979
Provider Name (Legal Business Name): TIMOTHY CHARLES VISGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 GRANT ST
DENNISON OH
44621-1219
US

IV. Provider business mailing address

401 GRANT ST
DENNISON OH
44621-1219
US

V. Phone/Fax

Practice location:
  • Phone: 740-922-2846
  • Fax: 740-264-6812
Mailing address:
  • Phone: 740-922-2846
  • Fax: 740-264-6812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.025951
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: