Healthcare Provider Details

I. General information

NPI: 1659375533
Provider Name (Legal Business Name): TIMOTHY RAY HUBER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 RIVERS AVE CODE 09MD.2
NORTH CHARLESTON SC
29405-7769
US

IV. Provider business mailing address

3600 RIVERS AVE CODE 09MD.2
NORTH CHARLESTON SC
29405-7769
US

V. Phone/Fax

Practice location:
  • Phone: 843-743-7868
  • Fax: 843-743-7521
Mailing address:
  • Phone: 843-743-7868
  • Fax: 843-743-7521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2854
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: