Provider Demographics
NPI:1528147089
Name:DUDLEY, TIMOTHY DAHL (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DAHL
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12808 N SCHICKS RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-9455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 E PARKCENTER BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-7536
Practice Address - Country:US
Practice Address - Phone:208-344-3610
Practice Address - Fax:208-344-4695
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA868111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU73254Medicare UPIN
ID1673819Medicare ID - Type Unspecified