Provider Demographics
NPI:1205972288
Name:DURHAM, TIMOTHY MARK (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MARK
Last Name:DURHAM
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 1:989375 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-9375
Mailing Address - Country:US
Mailing Address - Phone:402-559-7962
Mailing Address - Fax:402-559-9607
Practice Address - Street 1:989375 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-9375
Practice Address - Country:US
Practice Address - Phone:402-559-7962
Practice Address - Fax:402-559-9607
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE54281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1956599Medicaid
NE10025144400Medicaid
NE4851OtherBCBS
NE10025144400Medicaid