Provider Demographics
NPI:1417101551
Name:CREASMAN, SHANNON WAITS (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:WAITS
Last Name:CREASMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:WAITS
Other - Last Name:CREASMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:3330 PIEDMONT RD NE
Mailing Address - Street 2:STE 13
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1726
Mailing Address - Country:US
Mailing Address - Phone:404-237-5330
Mailing Address - Fax:404-237-5360
Practice Address - Street 1:3330 PIEDMONT RD NE
Practice Address - Street 2:STE 13
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-1726
Practice Address - Country:US
Practice Address - Phone:404-237-5330
Practice Address - Fax:404-237-5360
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0115751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice