Healthcare Provider Details

I. General information

NPI: 1942947858
Provider Name (Legal Business Name): NEO MAMORAKA EHIWE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2022
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 BEAVER RUIN RD NW
LILBURN GA
30047-3401
US

IV. Provider business mailing address

13760 ALDENBROOK DR
HUNTERSVILLE NC
28078-4232
US

V. Phone/Fax

Practice location:
  • Phone: 678-606-9407
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12916
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: