Healthcare Provider Details

I. General information

NPI: 1447195540
Provider Name (Legal Business Name): KEYANNA ENNIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2239 HIGHWAY 20 SE STE H
CONYERS GA
30013-2087
US

IV. Provider business mailing address

2239 HIGHWAY 20 SE STE H
CONYERS GA
30013-2087
US

V. Phone/Fax

Practice location:
  • Phone: 770-921-3565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN124171
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: