Healthcare Provider Details

I. General information

NPI: 1063416725
Provider Name (Legal Business Name): RUSSELL B TIMMS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 9TH AVE
LONGVIEW WA
98632-4005
US

IV. Provider business mailing address

2020 9TH AVE
LONGVIEW WA
98632-4005
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-5580
  • Fax: 360-423-5596
Mailing address:
  • Phone: 360-423-5580
  • Fax: 360-423-5596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4267
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1014
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: