Healthcare Provider Details

I. General information

NPI: 1881981181
Provider Name (Legal Business Name): SWL DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 E LAWRENCEVILLE ST
DULUTH GA
30096-3354
US

IV. Provider business mailing address

3415 E LAWRENCEVILLE ST P.O. BOX 610
DULUTH GA
30096-3354
US

V. Phone/Fax

Practice location:
  • Phone: 770-476-5227
  • Fax:
Mailing address:
  • Phone: 770-476-5227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number11701
License Number StateGA

VIII. Authorized Official

Name: DR. SLADE WALLACE LAIL
Title or Position: DENTIST/OWNER
Credential: D.D.S.
Phone: 770-476-5227