Healthcare Provider Details

I. General information

NPI: 1336296029
Provider Name (Legal Business Name): SHIVA HEJAZI-WERNER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12385 CRABAPPLE RD STE 100
ALPHARETTA GA
30004-6357
US

IV. Provider business mailing address

121 ESTATES AT THE LAKE DR
CANTON GA
30114-8839
US

V. Phone/Fax

Practice location:
  • Phone: 770-744-5595
  • Fax:
Mailing address:
  • Phone: 678-756-2726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN011904
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: