Healthcare Provider Details

I. General information

NPI: 1164591913
Provider Name (Legal Business Name): SUNDAY A FAWOLE DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2395 SCENIC HWY S
SNELLVILLE GA
30078-3134
US

IV. Provider business mailing address

2395 SCENIC HWY S
SNELLVILLE GA
30078-3134
US

V. Phone/Fax

Practice location:
  • Phone: 678-377-6830
  • Fax: 678-377-6836
Mailing address:
  • Phone: 678-377-6830
  • Fax: 678-377-6836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number55514
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDNO12698
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: