Healthcare Provider Details

I. General information

NPI: 1962498329
Provider Name (Legal Business Name): JEFFREY W TIMM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 NE EMERSON AVE
BEND OR
97701-4938
US

IV. Provider business mailing address

375 NE EMERSON AVE
BEND OR
97701-4938
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-1991
  • Fax: 541-330-9095
Mailing address:
  • Phone: 541-382-1991
  • Fax: 541-330-9095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5817
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: