Provider Demographics
NPI:1376929125
Name:SHAWN A. WALLS, DDS, PC
Entity Type:Organization
Organization Name:SHAWN A. WALLS, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-444-8485
Mailing Address - Street 1:10700 MEDLOCK BRIDGE RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8456
Mailing Address - Country:US
Mailing Address - Phone:404-444-8485
Mailing Address - Fax:770-814-7407
Practice Address - Street 1:10700 MEDLOCK BRIDGE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-8456
Practice Address - Country:US
Practice Address - Phone:404-444-8485
Practice Address - Fax:770-814-7407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0107151223G0001X
GA97111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty