Healthcare Provider Details

I. General information

NPI: 1104762905
Provider Name (Legal Business Name): SHEA SERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2570 BLACKMON DR STE 310
DECATUR GA
30033-6197
US

IV. Provider business mailing address

PO BOX 5006
KAHULUI HI
96733-5006
US

V. Phone/Fax

Practice location:
  • Phone: 678-203-3462
  • Fax:
Mailing address:
  • Phone: 808-281-5943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN124232
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: