Healthcare Provider Details

I. General information

NPI: 1679340368
Provider Name (Legal Business Name): MONTICELLO FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 W WASHINGTON ST
MONTICELLO GA
31064-1368
US

IV. Provider business mailing address

458 W WASHINGTON ST
MONTICELLO GA
31064-1368
US

V. Phone/Fax

Practice location:
  • Phone: 706-468-6394
  • Fax: 706-468-8113
Mailing address:
  • Phone: 706-468-6394
  • Fax: 706-468-8113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TYLER LIPHAM
Title or Position: OWNER/AGENT
Credential: DMD
Phone: 706-468-6394