Provider Demographics
NPI:1477649598
Name:FUSSELL, JAMES TIMOTHY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:TIMOTHY
Last Name:FUSSELL
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 1:1390 GORDON ST W
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-3432
Mailing Address - Country:US
Mailing Address - Phone:912-384-5474
Mailing Address - Fax:912-393-1001
Practice Address - Street 1:1390 GORDON ST W
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-3432
Practice Address - Country:US
Practice Address - Phone:912-384-5474
Practice Address - Fax:912-393-1001
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA105441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00350215AMedicaid