Provider Demographics
NPI:1871626838
Name:TIMOTHY V WINEGARDEN DDS MSD PC
Entity type:Organization
Organization Name:TIMOTHY V WINEGARDEN DDS MSD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:V
Authorized Official - Last Name:WINEGARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD PC
Authorized Official - Phone:319-396-8364
Mailing Address - Street 1:222 EDGEWOOD RD NW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52405-4472
Mailing Address - Country:US
Mailing Address - Phone:319-396-8364
Mailing Address - Fax:319-396-5800
Practice Address - Street 1:222 EDGEWOOD RD NW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52405-4472
Practice Address - Country:US
Practice Address - Phone:319-396-8364
Practice Address - Fax:319-396-5800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA58061223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0142687Medicaid