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General NPI Number Information
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NPI Number | 1811121445
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Entity Type | Organization
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Legal Business Name | VAN TUYL DENTAL GROUP
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Dates
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Enumeration Date | 05/11/2009
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Last Update Date | 05/11/2009
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Provider Practice Location Address
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Address Line | 929 COVE RD SUITE F
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City | JASPER
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State | GA
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Zip | 30143-4444
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Country | US
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Telephone | 706-692-3759
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Fax |
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Provider Business Mailing Address
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Address Line | 929 COVE RD SUITE F
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City | JASPER
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State | GA
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Zip | 30143-4444
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Country | US
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Telephone | 706-692-3759
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JAMIE L DICKERSON
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Credential |
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Telephone | 770-345-6600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN013002
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License Number State | GA
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