MEDICARE: DR. DAKOTA JORDAN TYRUS THARPE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN122698	GA

General Provider Information

NPI Number	:	1417687054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAKOTA JORDAN TYRUS THARPE DMD

Provider Business Mailing Address
First Line	:	3947 JORDAN RD
Second Line	:
City	:	BYRON
State	:	GA
Zip	:	31008-7707
Country	:	US
Telephone Number	:	478-217-6805
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 DAWSON RD
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31707-3362
Country	:	US
Telephone Number	:	229-883-7891
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2022
Last Update Date	:	06/15/2022

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