Provider Demographics
NPI:1891937470
Name:WENTZLOFF, TIMOTHY DONALD (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DONALD
Last Name:WENTZLOFF
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 1:6597 DEEPWATER POINT RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49690-9246
Mailing Address - Country:US
Mailing Address - Phone:231-383-0382
Mailing Address - Fax:
Practice Address - Street 1:876 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2704
Practice Address - Country:US
Practice Address - Phone:231-947-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010200151223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program