Healthcare Provider Details

I. General information

NPI: 1174276026
Provider Name (Legal Business Name): SHANNON WALLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 07/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3255 11 AIRBORNE DIVISION ROAD
FORT BENNING GA
31801
US

IV. Provider business mailing address

3255 11 AIRBORNE DIVISION ROAD
FORT BENNING GA
31801
US

V. Phone/Fax

Practice location:
  • Phone: 706-544-9071
  • Fax:
Mailing address:
  • Phone: 706-544-9071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: