Provider Demographics
NPI:1437676244
Name:DAVIS, EJUAN (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:MS
First Name:EJUAN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:MISS
Other - First Name:EJUAN
Other - Middle Name:DAVIS
Other - Last Name:SMALLWOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:HLS
Mailing Address - Street 1:19 CENTENNIAL LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-0256
Mailing Address - Country:US
Mailing Address - Phone:404-834-0396
Mailing Address - Fax:
Practice Address - Street 1:5043 JIMMY LEE SMITH PKWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2733
Practice Address - Country:US
Practice Address - Phone:404-834-0396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No174400000XOther Service ProvidersSpecialist
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other