Provider Demographics
NPI:1194897413
Name:CLAVIN, TIMOTHY JOHN (DDS,)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:CLAVIN
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 1:825 NICOLLET MALL
Mailing Address - Street 2:SUITE 609
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-2606
Mailing Address - Country:US
Mailing Address - Phone:612-332-5122
Mailing Address - Fax:612-332-7712
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:SUITE 609
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2606
Practice Address - Country:US
Practice Address - Phone:612-332-5122
Practice Address - Fax:612-332-7712
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10647OtherSTATE ID