Organization
TIFT REGIONAL DENTAL GROUP, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ANGELA WALLER (SECRETARY)
(229) 382-0467
Entity
Organization
Contact information
Practice address
209 24TH ST E, TIFTON, GA 31794-3170
(229) 382-0467
Mailing address
PO BOX 1295, TIFTON, GA 31793-1295
(229) 382-0467
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
111718
—
GA
05
—
40104
—
GA
Enumeration date
11/06/2006
Last updated
09/12/2008
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