Healthcare Provider Details

I. General information

NPI: 1154082337
Provider Name (Legal Business Name): SARAH KANCHWALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 HERITAGE WALK
WOODSTOCK GA
30188-3876
US

IV. Provider business mailing address

271 HERITAGE WALK
WOODSTOCK GA
30188-3876
US

V. Phone/Fax

Practice location:
  • Phone: 770-924-0423
  • Fax:
Mailing address:
  • Phone: 630-770-1653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN124128
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number600142515
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: