Provider Demographics
NPI:1447480983
Name:PRICE, TIMOTHY BRENT (DDS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BRENT
Last Name:PRICE
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 1:313 W COUNTRY CLUB RD
Mailing Address - Street 2:#6
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5804
Mailing Address - Country:US
Mailing Address - Phone:575-622-3300
Mailing Address - Fax:575-625-9018
Practice Address - Street 1:313 W COUNTRY CLUB RD
Practice Address - Street 2:#6
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5804
Practice Address - Country:US
Practice Address - Phone:575-622-3300
Practice Address - Fax:575-625-9018
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-17
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD31191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice