Healthcare Provider Details

I. General information

NPI: 1215054051
Provider Name (Legal Business Name): WALLIS HOBBY D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E COLLEGE AVE
ASHBURN GA
31714-5209
US

IV. Provider business mailing address

PO BOX 2569
ASHBURN GA
31714-2569
US

V. Phone/Fax

Practice location:
  • Phone: 229-326-4801
  • Fax:
Mailing address:
  • Phone: 229-326-4801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN013114
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: