MEDICARE: TIMOTHY G CASE DMD LLC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1841742335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMOTHY G CASE DMD LLC

Provider Business Mailing Address
First Line	:	4300 HOLLY HILLS BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-2253
Country	:	US
Telephone Number	:	314-351-5555
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 HOLLY HILLS BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-2253
Country	:	US
Telephone Number	:	314-351-5555
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TIM CASE
Credential	:	DMD
Telephone Number	:	314-351-5555

Provider Enumeration Date	:	10/31/2016
Last Update Date	:	10/31/2016

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