Healthcare Provider Details

I. General information

NPI: 1114069424
Provider Name (Legal Business Name): HANK R. DALLAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 EAGLES LANDING PKWY SUITE 200
STOCKBRIDGE GA
30281-9072
US

IV. Provider business mailing address

1611 WATERFORD LNDG
MCDONOUGH GA
30253-7726
US

V. Phone/Fax

Practice location:
  • Phone: 770-968-3302
  • Fax: 770-441-0299
Mailing address:
  • Phone: 770-331-2529
  • Fax: 770-441-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN013071
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: