Healthcare Provider Details

I. General information

NPI: 1235587908
Provider Name (Legal Business Name): WILEY LIPSCOMB PURCELL D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 WHEELER RD
AUGUSTA GA
30909-6626
US

IV. Provider business mailing address

3636 WHEELER RD
AUGUSTA GA
30909-6626
US

V. Phone/Fax

Practice location:
  • Phone: 706-869-9117
  • Fax:
Mailing address:
  • Phone: 706-869-9117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN015381
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDN015381
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN015381
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: