Provider Demographics
NPI:1245779701
Name:SCHAFER, NOELAN
Entity Type:Individual
Prefix:
First Name:NOELAN
Middle Name:
Last Name:SCHAFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4795 SUGARLOAF PARKWAY
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519
Mailing Address - Country:US
Mailing Address - Phone:470-223-3532
Mailing Address - Fax:
Practice Address - Street 1:2946 WINFIELD DUNN PKWY STE 301
Practice Address - Street 2:
Practice Address - City:KODAK
Practice Address - State:TN
Practice Address - Zip Code:37764-4319
Practice Address - Country:US
Practice Address - Phone:865-465-7058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0157141223G0001X
390200000X
TN105721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program