Healthcare Provider Details

I. General information

NPI: 1003562802
Provider Name (Legal Business Name): DIVYA CHAWLA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 BEGONIA WAY
DALLAS GA
30132-0990
US

IV. Provider business mailing address

750 MILTON OAKS DR
JOHNS CREEK GA
30022-8197
US

V. Phone/Fax

Practice location:
  • Phone: 770-241-4774
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN122831
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDN122831
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: