Provider Demographics
NPI:1083176275
Name:SHAW, KEYANNI JHAMIA (DDS)
Entity Type:Individual
Prefix:
First Name:KEYANNI
Middle Name:JHAMIA
Last Name:SHAW
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11409 PANHANDLE RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-1504
Mailing Address - Country:US
Mailing Address - Phone:770-572-4915
Mailing Address - Fax:
Practice Address - Street 1:6351 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7102
Practice Address - Country:US
Practice Address - Phone:404-267-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.96641223G0001X
GADN122281122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty