Provider Demographics
NPI:1083867493
Name:ERATTUPARAMBIL, SHABANA QAYYUM (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHABANA
Middle Name:QAYYUM
Last Name:ERATTUPARAMBIL
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 1:2715 LOGANVILLE HWY
Mailing Address - Street 2:#340-3D
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6660
Mailing Address - Country:US
Mailing Address - Phone:678-956-1381
Mailing Address - Fax:
Practice Address - Street 1:2715 LOGANVILLE HWY
Practice Address - Street 2:#340-3D
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-6660
Practice Address - Country:US
Practice Address - Phone:678-956-1381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014005122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist