Basic Information
| Provider Information | |||||||||
| NPI: | 1124081880 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GERETY | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4101 S 4TH STREET | ||||||||
| Address2: | DENTAL CLINIC, L-160 | ||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660485055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136822000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4101 S 4TH STREET | ||||||||
| Address2: | DENTAL CLINIC, L-160 | ||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660485055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136822000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 6131 | KS | Y | Dental Providers | Dentist | General Practice |
No ID Information.