Provider Demographics
NPI:1447254305
Name:DURTSCHE, TIMOTHY BREKKE (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:BREKKE
Last Name:DURTSCHE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 10TH ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4768
Mailing Address - Country:US
Mailing Address - Phone:608-784-7319
Mailing Address - Fax:608-784-4384
Practice Address - Street 1:615 10TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4768
Practice Address - Country:US
Practice Address - Phone:608-784-7319
Practice Address - Fax:608-784-4384
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22441223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33388200(PERFORMING)Medicaid
WI38365100 (BILLING#)Medicaid
WI33388200(PERFORMING)Medicaid
WI38365100 (BILLING#)Medicaid