Provider Demographics
NPI:1063798718
Name:TIMBER CREEK ORTHODONTICS, P.A.
Entity type:Organization
Organization Name:TIMBER CREEK ORTHODONTICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MALLORY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:817-562-3292
Mailing Address - Street 1:12650 N BEACH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4243
Mailing Address - Country:US
Mailing Address - Phone:817-562-3292
Mailing Address - Fax:
Practice Address - Street 1:12650 N BEACH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-4243
Practice Address - Country:US
Practice Address - Phone:817-562-3292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX206251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty