Healthcare Provider Details

I. General information

NPI: 1093411910
Provider Name (Legal Business Name): SHAWN A. WALLS, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 MEDLOCK BRIDGE RD. SUITE 202
JOHNS CREEK GA
30097
US

IV. Provider business mailing address

10700 MEDLOCK BRIDGE RD. SUITE 202
JOHNS CREEK GA
30097
US

V. Phone/Fax

Practice location:
  • Phone: 770-813-0079
  • Fax: 770-814-7407
Mailing address:
  • Phone: 770-813-0079
  • Fax: 770-814-7407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: SHAWN A WALLS
Title or Position: PRESIDENT/DENTIST
Credential: DDS
Phone: 770-813-0079