Healthcare Provider Details

I. General information

NPI: 1003259797
Provider Name (Legal Business Name): TIMOTHY MCMICHAEL THEISEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TIMOTHY MCMICHAEL THEISEN DMD

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 PEACH ST
ERIE PA
16509-1443
US

IV. Provider business mailing address

4330 PEACH ST
ERIE PA
16509-1443
US

V. Phone/Fax

Practice location:
  • Phone: 814-315-6209
  • Fax: 814-315-6303
Mailing address:
  • Phone: 814-315-6209
  • Fax: 814-315-6303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS038461
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS038461
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS038461
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS038461
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS038461
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: