Individual
MR. TIMOTHY MCMICHAEL THEISEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
4330 PEACH ST, ERIE, PA 16509-1443
(814) 315-6209
(814) 315-6303
Mailing address
4330 PEACH ST, ERIE, PA 16509-1443
(814) 315-6209
(814) 315-6303
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DS038461
PA
1223E0200X
Endodontics
DS038461
PA
1223G0001X
General Practice Dentistry
DS038461
PA
1223P0221X
Pediatric Dentistry
DS038461
PA
1223P0700X
Prosthodontics
DS038461
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
056582
NYS LICENSE
NY
Enumeration date
04/11/2013
Last updated
08/09/2021
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