Provider Demographics
NPI:1386693984
Name:JENNESS, TIMOTHY ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ALAN
Last Name:JENNESS
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:W184S6668 JEWEL CREST DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-8503
Mailing Address - Country:US
Mailing Address - Phone:262-853-8927
Mailing Address - Fax:
Practice Address - Street 1:4040 N CALHOUN RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-1336
Practice Address - Country:US
Practice Address - Phone:262-781-8927
Practice Address - Fax:262-781-6357
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice