MEDICARE: TIMANISHA HOLBERT I

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	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	8233	OK

General Provider Information

NPI Number	:	1811691363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMANISHA HOLBERT I

Provider Business Mailing Address
First Line	:	3302 GASTON AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75246-2013
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1137 E KENOSHA ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-2006
Country	:	US
Telephone Number	:	918-259-0239
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2023
Last Update Date	:	05/19/2026

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Directions to “ TIMANISHA HOLBERT I ” Practice Location

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