Healthcare Provider Details

I. General information

NPI: 1649296211
Provider Name (Legal Business Name): LYKINS FAMILY DENTISTRY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 HIGHLAND CT STE 202
EAST ELLIJAY GA
30540-6772
US

IV. Provider business mailing address

60 HIGHLAND CT STE 202
EAST ELLIJAY GA
30540-6772
US

V. Phone/Fax

Practice location:
  • Phone: 706-698-3384
  • Fax: 706-698-3383
Mailing address:
  • Phone: 706-698-3384
  • Fax: 706-698-3383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN012553
License Number StateGA

VIII. Authorized Official

Name: SHAY DANIELS LYKINS
Title or Position: DENTIST/OWNER
Credential: D.M.D.
Phone: 706-698-3384