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General NPI Number Information
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NPI Number | 1083176275
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Entity Type | Individual
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Provider Name | KEYANNI JHAMIA SHAW DDS
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Gender | Female
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Dates
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Enumeration Date | 04/05/2019
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Last Update Date | 07/22/2021
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Provider Practice Location Address
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Address Line | 6351 DOUGLAS BLVD
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City | DOUGLASVILLE
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State | GA
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Zip | 30135-7102
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Country | US
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Telephone | 404-267-0400
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Fax |
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Provider Business Mailing Address
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Address Line | 11409 PANHANDLE RD
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City | HAMPTON
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State | GA
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Zip | 30228-1504
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Country | US
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Telephone | 770-572-4915
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DGD.9664
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN122281
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License Number State | GA
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