Healthcare Provider Details

I. General information

NPI: 1417112335
Provider Name (Legal Business Name): TIMOTHY JAY VOSTERS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2214 E EVERGREEN DR
APPLETON WI
54913-9002
US

IV. Provider business mailing address

2214 E EVERGREEN DR
APPLETON WI
54913-9002
US

V. Phone/Fax

Practice location:
  • Phone: 920-739-3936
  • Fax: 920-882-8653
Mailing address:
  • Phone: 920-739-3936
  • Fax: 920-882-8653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3583-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: