Healthcare Provider Details

I. General information

NPI: 1821583782
Provider Name (Legal Business Name): TYLER KEITH LIPHAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2018
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

120 DELL AVE
ATHENS GA
30606-3406
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN015668
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: