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NPI Code Detail

MEDICARE: DR. TIM MICAH SUPIN D.M.D.

MEDICARE: DR. TIM MICAH SUPIN D.M.D.
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
1122300000XDentistDE00010813WA

General Provider Information

NPI Number : 1538362256
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. TIM MICAH SUPIN D.M.D.
Provider Business Mailing Address
First Line : 1412 NE 88TH ST
Second Line :
City : VANCOUVER
State : WA
Zip : 98665-9620
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1412 NE 88TH ST
Second Line :
City : VANCOUVER
State : WA
Zip : 98665-9620
Country : US
Telephone Number : 360-574-4074
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/08/2007
Last Update Date : 07/31/2013

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Directions to “ DR. TIM MICAH SUPIN D.M.D.” Practice Location

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