Healthcare Provider Details

I. General information

NPI: 1285948414
Provider Name (Legal Business Name): JOHN W SCHAEFER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 12TH ST NE STE 1B
ATLANTA GA
30309-4009
US

IV. Provider business mailing address

222 12TH ST NE STE 1B
ATLANTA GA
30309-4009
US

V. Phone/Fax

Practice location:
  • Phone: 404-815-4800
  • Fax: 404-815-0002
Mailing address:
  • Phone: 404-815-4800
  • Fax: 404-815-0002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.029281
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN 18094
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021.002499
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2012010128
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN016082
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: