Provider Demographics
NPI:1104819515
Name:CLEGG, TIMOTHY J (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:CLEGG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36975 UTICA RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1685
Mailing Address - Country:US
Mailing Address - Phone:586-226-2801
Mailing Address - Fax:586-226-1519
Practice Address - Street 1:36975 UTICA RD
Practice Address - Street 2:SUITE 106
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-1685
Practice Address - Country:US
Practice Address - Phone:586-226-2801
Practice Address - Fax:586-226-0929
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0120431223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU21482Medicare UPIN
MI0E06224Medicare ID - Type Unspecified