Provider Demographics
NPI:1679854517
Name:IRISH, TIMOTHY DEAN (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DEAN
Last Name:IRISH
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 5TH ST W
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-6830
Mailing Address - Country:US
Mailing Address - Phone:707-935-6878
Mailing Address - Fax:707-935-6811
Practice Address - Street 1:699 5TH ST W
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-6830
Practice Address - Country:US
Practice Address - Phone:707-935-6878
Practice Address - Fax:707-935-6811
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA385441223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics