Provider Demographics
NPI:1821583782
Name:LIPHAM, TYLER KEITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:KEITH
Last Name:LIPHAM
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 1:120 DELL AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:458 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:GA
Practice Address - Zip Code:31064-1368
Practice Address - Country:US
Practice Address - Phone:706-468-6394
Practice Address - Fax:706-468-8113
Is Sole Proprietor?:No
Enumeration Date:2018-06-24
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0156681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice