Provider Demographics
NPI:1386869899
Name:TIMM, KEVIN R (DDS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:TIMM
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 1:4519 PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49254-1039
Mailing Address - Country:US
Mailing Address - Phone:517-764-3870
Mailing Address - Fax:517-764-6787
Practice Address - Street 1:4519 PAGE AVE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49254-1039
Practice Address - Country:US
Practice Address - Phone:517-764-3870
Practice Address - Fax:517-764-6787
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010167641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice