Provider Demographics
NPI:1952525776
Name:LIM, TONY U (DDS)
Entity Type:Individual
Prefix:DR
First Name:TONY
Middle Name:U
Last Name:LIM
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 1:102 NORTH CENTRAL AVE
Mailing Address - Street 2:P. O. BOX 433
Mailing Address - City:ADAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30103
Mailing Address - Country:US
Mailing Address - Phone:770-773-7311
Mailing Address - Fax:
Practice Address - Street 1:102 NORTH CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103
Practice Address - Country:US
Practice Address - Phone:770-773-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA120541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00887719AMedicaid