Provider Demographics
NPI:1427018878
Name:TALLEY, PHILIP K (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:K
Last Name:TALLEY
Suffix:
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 1:2055 BEAVER RUIN RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-3607
Mailing Address - Country:US
Mailing Address - Phone:770-242-0021
Mailing Address - Fax:770-242-6016
Practice Address - Street 1:2055 BEAVER RUIN RD
Practice Address - Street 2:SUITE E
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-3607
Practice Address - Country:US
Practice Address - Phone:770-242-0021
Practice Address - Fax:770-242-6016
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA119701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00934601AMedicaid