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General NPI Number Information
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NPI Number | 1104483791
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Entity Type | Individual
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Provider Name | TIM GOUGH DDS
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Gender | Male
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Dates
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Enumeration Date | 05/20/2019
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Last Update Date | 11/22/2019
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Provider Practice Location Address
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Address Line | 9010 HARFORD RD
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City | PARKVILLE
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State | MD
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Zip | 21234-4033
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Country | US
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Telephone | 410-665-2202
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Fax | 410-665-9008
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Provider Business Mailing Address
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Address Line | 2410 RAVENVIEW RD
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City | TIMONIUM
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State | MD
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Zip | 21093-2716
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Country | US
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Telephone | 410-252-3526
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 17197
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License Number State | MD
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