Healthcare Provider Details

I. General information

NPI: 1710502778
Provider Name (Legal Business Name): CHANTAI NACOLE HARRIS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 WISTERIA DR STE 300
SNELLVILLE GA
30078-4604
US

IV. Provider business mailing address

2233 ROLLING ACRES DR SW
CONYERS GA
30094-6137
US

V. Phone/Fax

Practice location:
  • Phone: 678-836-2107
  • Fax:
Mailing address:
  • Phone: 770-876-3871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN122640
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: