Provider Demographics
NPI:1699896282
Name:TYMIUK, PETRO MYCHAJLO (DDS)
Entity type:Individual
Prefix:DR
First Name:PETRO
Middle Name:MYCHAJLO
Last Name:TYMIUK
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 1:508 S WOLFE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-3008
Mailing Address - Country:US
Mailing Address - Phone:410-342-1729
Mailing Address - Fax:
Practice Address - Street 1:10316A BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-2128
Practice Address - Country:US
Practice Address - Phone:410-313-9483
Practice Address - Fax:410-313-9482
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD116111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice