Provider Demographics
NPI:1144469016
Name:TIM F. CRISP DMD
Entity type:Organization
Organization Name:TIM F. CRISP DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:FELIX
Authorized Official - Last Name:CRISP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-744-7031
Mailing Address - Street 1:11 CANARY LN
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-1645
Mailing Address - Country:US
Mailing Address - Phone:859-744-7031
Mailing Address - Fax:859-744-9175
Practice Address - Street 1:11 CANARY LN
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1645
Practice Address - Country:US
Practice Address - Phone:859-744-7031
Practice Address - Fax:859-744-9175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty