Healthcare Provider Details

I. General information

NPI: 1083062814
Provider Name (Legal Business Name): SCHARON M WALLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 11/18/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9676 OLD CUSSETA RD. BLDG 4202 USA DENTAL ACTIVITY
FORT BENNING GA
31905-5645
US

IV. Provider business mailing address

5976 WALTERS LOOP
COLUMBUS GA
31907-5363
US

V. Phone/Fax

Practice location:
  • Phone: 706-544-3176
  • Fax:
Mailing address:
  • Phone: 762-822-4733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: