Healthcare Provider Details

I. General information

NPI: 1801907076
Provider Name (Legal Business Name): TIMOTHY M MCBRIDE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 HARBOR VIEW DR
FOND DU LAC WI
54935
US

IV. Provider business mailing address

336 HARBOR VIEW DR
FOND DU LAC WI
54935
US

V. Phone/Fax

Practice location:
  • Phone: 920-922-9400
  • Fax: 920-921-3260
Mailing address:
  • Phone: 920-922-9400
  • Fax: 920-921-3260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number3702
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: