Provider Demographics
NPI:1154690337
Name:TILLMAN, HENRY YOUNG III (DDS)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:YOUNG
Last Name:TILLMAN
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 554
Mailing Address - Street 2:
Mailing Address - City:HAHIRA
Mailing Address - State:GA
Mailing Address - Zip Code:31632-0554
Mailing Address - Country:US
Mailing Address - Phone:229-251-0099
Mailing Address - Fax:229-247-5828
Practice Address - Street 1:950 HWY 122 W
Practice Address - Street 2:
Practice Address - City:HAHIRA
Practice Address - State:GA
Practice Address - Zip Code:31632-1061
Practice Address - Country:US
Practice Address - Phone:229-794-3003
Practice Address - Fax:229-794-3804
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-18
Last Update Date:2011-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0069261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice