Provider Demographics
NPI:1194776856
Name:TALLY, PAUL MILES (DDS)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:MILES
Last Name:TALLY
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 1:5300 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2924
Mailing Address - Country:US
Mailing Address - Phone:313-928-6684
Mailing Address - Fax:313-928-8846
Practice Address - Street 1:5300 ALLEN RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2924
Practice Address - Country:US
Practice Address - Phone:313-928-6684
Practice Address - Fax:313-928-8846
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI145811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice