MEDICARE: TIMOTHY R. HARBOLT, DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D6816	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D6816	OTHER	OR	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1114924933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMOTHY R. HARBOLT, DMD

Provider Business Mailing Address
First Line	:	4734 RIVER RD N
Second Line	:
City	:	KEIZER
State	:	OR
Zip	:	97303-4536
Country	:	US
Telephone Number	:	503-463-4663
Fax Number	:	503-463-4666

Provider Business Practice Location Address
First Line	:	4734 RIVER RD N
Second Line	:
City	:	KEIZER
State	:	OR
Zip	:	97303-4536
Country	:	US
Telephone Number	:	503-463-4663
Fax Number	:	503-463-4666

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TIMOTHY R. HARBOLT
Credential	:	D.M.D.
Telephone Number	:	503-551-6349

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	09/10/2012

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