Provider Demographics
NPI:1104043066
Name:TILLEY, LARRY LAMAR (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:LAMAR
Last Name:TILLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S. PARK AVE.
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-2441
Mailing Address - Country:US
Mailing Address - Phone:706-629-0131
Mailing Address - Fax:706-629-0299
Practice Address - Street 1:201 S. PARK AVE.
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-2441
Practice Address - Country:US
Practice Address - Phone:706-629-0131
Practice Address - Fax:706-629-0299
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA85551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice