MEDICARE: TONY MONROE DELOACH D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	7299	GA

General Provider Information

NPI Number	:	1891931259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONY MONROE DELOACH D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 1290
Second Line	:
City	:	PERRY
State	:	GA
Zip	:	31069-1290
Country	:	US
Telephone Number	:	404-295-8845
Fax Number	:

Provider Business Practice Location Address
First Line	:	1113 MORNINGSIDE DR
Second Line	:
City	:	PERRY
State	:	GA
Zip	:	31069-2905
Country	:	US
Telephone Number	:	404-295-8846
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2009
Last Update Date	:	01/07/2009

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