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General NPI Number Information
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NPI Number | 1851460075
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Entity Type | Organization
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Legal Business Name | TIFT REGIONAL DENTAL GROUP, PC
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Dates
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Enumeration Date | 11/06/2006
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Last Update Date | 09/12/2008
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Provider Practice Location Address
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Address Line | 209 24TH ST E
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City | TIFTON
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State | GA
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Zip | 31794-3170
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Country | US
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Telephone | 229-382-0467
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1295
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City | TIFTON
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State | GA
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Zip | 31793-1295
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Country | US
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Telephone | 229-382-0467
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Fax |
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Authorized Official
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Title or Position | SECRETARY
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Name | ANGELA WALLER
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Credential |
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Telephone | 229-382-0467
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State | GA
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