Provider Demographics
NPI:1154403194
Name:KOLL, TIMOTHY JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:KOLL
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 1:2410 E. EVERGREEN DR.
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-4913
Mailing Address - Country:US
Mailing Address - Phone:920-832-9500
Mailing Address - Fax:920-832-9490
Practice Address - Street 1:2410 E. EVERGREEN DR.
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-4913
Practice Address - Country:US
Practice Address - Phone:920-832-9500
Practice Address - Fax:920-832-9490
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42431223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4-19648Medicare UPIN
WI78325Medicare ID - Type Unspecified