Provider Demographics
NPI:1801105556
Name:TIMBERLAND DENTAL, PC
Entity type:Organization
Organization Name:TIMBERLAND DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:HUGER
Authorized Official - Last Name:HOUSTON
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:251-580-0979
Mailing Address - Street 1:301 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BAY MINETTE
Mailing Address - State:AL
Mailing Address - Zip Code:36507-4029
Mailing Address - Country:US
Mailing Address - Phone:251-580-0979
Mailing Address - Fax:251-580-0971
Practice Address - Street 1:301 E 1ST ST
Practice Address - Street 2:
Practice Address - City:BAY MINETTE
Practice Address - State:AL
Practice Address - Zip Code:36507-4029
Practice Address - Country:US
Practice Address - Phone:251-580-0979
Practice Address - Fax:251-580-0971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5114261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-38527OtherBC/BS
AL009931835Medicaid