Provider Demographics
NPI:1578643920
Name:TULLY, PHILLIP SHELBY III (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:SHELBY
Last Name:TULLY
Suffix:III
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 1:8109 WOOD FERN DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2027
Mailing Address - Country:US
Mailing Address - Phone:706-507-4296
Mailing Address - Fax:706-323-2671
Practice Address - Street 1:3914 ROSEMONT DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5626
Practice Address - Country:US
Practice Address - Phone:706-323-6491
Practice Address - Fax:706-323-2671
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAV07432Medicare UPIN
GA19NCCFCMedicare ID - Type UnspecifiedCARRIER PROVIDER NUMBER