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General NPI Number Information
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NPI Number | 1447796560
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Entity Type | Organization
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Legal Business Name | CONYERS DENTAL ASSOCIATES, LLC
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Dates
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Enumeration Date | 01/12/2017
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Last Update Date | 01/12/2017
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Provider Practice Location Address
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Address Line | 1455 OLD MCDONOUGH HWY SE SUITE B
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City | CONYERS
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State | GA
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Zip | 30094-5979
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Country | US
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Telephone | 770-483-6655
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Fax |
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Provider Business Mailing Address
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Address Line | 1455 OLD MCDONOUGH HWY SE SUITE B
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City | CONYERS
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State | GA
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Zip | 30094-5979
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Country | US
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Telephone | 770-483-6655
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. SHAWN A WALLS
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Credential | DDS
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Telephone | 404-444-8485
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN 010715
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License Number State | GA
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