Healthcare Provider Details

I. General information

NPI: 1154403194
Provider Name (Legal Business Name): TIMOTHY JAMES KOLL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 E. EVERGREEN DR.
APPLETON WI
54913-4913
US

IV. Provider business mailing address

2410 E. EVERGREEN DR.
APPLETON WI
54913-4913
US

V. Phone/Fax

Practice location:
  • Phone: 920-832-9500
  • Fax: 920-832-9490
Mailing address:
  • Phone: 920-832-9500
  • Fax: 920-832-9490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number4243
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: