Healthcare Provider Details

I. General information

NPI: 1174366579
Provider Name (Legal Business Name): ANJELICA TYRELL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5461 MERIDIAN MARK RD STE 200
ATLANTA GA
30342-4014
US

IV. Provider business mailing address

5461 MERIDIAN MARK RD STE 200
ATLANTA GA
30342-4014
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-3627
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN123647
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: