Provider Demographics
NPI:1992990873
Name:TIPTON, DUSTIN SHANE (DDS)
Entity type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:SHANE
Last Name:TIPTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 195
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188
Mailing Address - Country:US
Mailing Address - Phone:678-445-5444
Mailing Address - Fax:770-874-0825
Practice Address - Street 1:2230 TOWNE LAKE PKWY
Practice Address - Street 2:BLDG 1100 SUITE 100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189
Practice Address - Country:US
Practice Address - Phone:678-445-5444
Practice Address - Fax:678-445-5552
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0134971223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics