Provider Demographics
NPI:1861752560
Name:TIMOTHY M LETHIN DDS PC
Entity type:Organization
Organization Name:TIMOTHY M LETHIN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LETHIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-337-9474
Mailing Address - Street 1:2601 BONIFACE PKWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-3144
Mailing Address - Country:US
Mailing Address - Phone:907-337-9474
Mailing Address - Fax:
Practice Address - Street 1:2601 BONIFACE PKWY
Practice Address - Street 2:SUITE 2
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-3144
Practice Address - Country:US
Practice Address - Phone:907-337-9474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1207122300000X
AK213122300000X
AK1133122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDDO6052Medicaid