Provider Demographics
NPI:1285786194
Name:PENBERTHY, TIMOTHY WALTER (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WALTER
Last Name:PENBERTHY
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 1:509 W HANLEY AVE
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8994
Mailing Address - Country:US
Mailing Address - Phone:208-664-8622
Mailing Address - Fax:
Practice Address - Street 1:509 W HANLEY AVE
Practice Address - Street 2:SUITE # 2
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8994
Practice Address - Country:US
Practice Address - Phone:208-664-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1930-EN1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics