=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679650717
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANA G ELLIOTT DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4205 NORTH POINT PARKWAY BLDG E
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-475-4449
-----------------------------------------------------
Fax | 770-569-0945
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4205 NORTH POINT PARKWAY BLDG E
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-475-4449
-----------------------------------------------------
Fax | 770-569-0945
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 010314
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------