Provider Demographics
NPI:1023484805
Name:LEVIE, TYLER KELLUM (DDS)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:KELLUM
Last Name:LEVIE
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 1:201 E. VILLANOW STREET
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728
Mailing Address - Country:US
Mailing Address - Phone:706-638-2784
Mailing Address - Fax:706-638-7428
Practice Address - Street 1:201 E. VILLANOW STREET
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728
Practice Address - Country:US
Practice Address - Phone:706-638-2784
Practice Address - Fax:706-638-7428
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015053122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist