Healthcare Provider Details

I. General information

NPI: 1437725090
Provider Name (Legal Business Name): WACS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3993 LAWRENCEVILLE HWY NW STE 100
LILBURN GA
30047-2831
US

IV. Provider business mailing address

410 BRAEDEN WAY
ALPHARETTA GA
30009-3005
US

V. Phone/Fax

Practice location:
  • Phone: 770-279-2020
  • Fax:
Mailing address:
  • Phone: 510-847-5112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM SHIN
Title or Position: ORAL AND MAXILLOFACIAL SURGEON
Credential: DDS, MS
Phone: 510-847-5112