Provider Demographics
NPI:1992944698
Name:TIMOTHY D WEZEMAN DDS PC
Entity type:Organization
Organization Name:TIMOTHY D WEZEMAN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WEZEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-679-1581
Mailing Address - Street 1:926 E WHIDBEY AVE
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-2674
Mailing Address - Country:US
Mailing Address - Phone:360-679-1581
Mailing Address - Fax:360-679-4818
Practice Address - Street 1:926 E WHIDBEY AVE
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-2674
Practice Address - Country:US
Practice Address - Phone:360-679-1581
Practice Address - Fax:360-679-4818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4813261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4813OtherLICENSE