Provider Demographics
NPI:1932123692
Name:TALLEY, BRIAN C (DMD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
Last Name:TALLEY
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 1:5811 JACK SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:ATMORE
Mailing Address - State:AL
Mailing Address - Zip Code:36502-5025
Mailing Address - Country:US
Mailing Address - Phone:251-368-9136
Mailing Address - Fax:251-446-7211
Practice Address - Street 1:429 BUFORD L ROLIN DR
Practice Address - Street 2:
Practice Address - City:ATMORE
Practice Address - State:AL
Practice Address - Zip Code:36502-5190
Practice Address - Country:US
Practice Address - Phone:251-368-9136
Practice Address - Fax:251-446-7211
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3223-021223P0221X
CO97281223P0221X
ALD.007389-C1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM90953614Medicaid