Healthcare Provider Details

I. General information

NPI: 1881371011
Provider Name (Legal Business Name): SELOME WONDAFRASH ABERA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 W BANKHEAD HWY
VILLA RICA GA
30180-1702
US

IV. Provider business mailing address

1960 SPECTRUM CIR SE # 915
MARIETTA GA
30067-6087
US

V. Phone/Fax

Practice location:
  • Phone: 770-456-2550
  • Fax:
Mailing address:
  • Phone: 704-713-1305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN123147
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: