Provider Demographics
NPI:1861562738
Name:TIMOTHY, MARY ELIZABETH (RDH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:TIMOTHY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9137 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93505-2806
Mailing Address - Country:US
Mailing Address - Phone:760-373-2049
Mailing Address - Fax:
Practice Address - Street 1:95TH MEDICAL GROUP SGDH
Practice Address - Street 2:30 NIGHTINGALE RD
Practice Address - City:EDWARDS AFB
Practice Address - State:CA
Practice Address - Zip Code:93524-1760
Practice Address - Country:US
Practice Address - Phone:661-277-2872
Practice Address - Fax:661-277-4728
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20888124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist