Provider Demographics
NPI:1447796560
Name:CONYERS DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:CONYERS DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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 1:1455 OLD MCDONOUGH HWY SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5979
Mailing Address - Country:US
Mailing Address - Phone:770-483-6655
Mailing Address - Fax:
Practice Address - Street 1:1455 OLD MCDONOUGH HWY SE
Practice Address - Street 2:SUITE B
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5979
Practice Address - Country:US
Practice Address - Phone:770-483-6655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN 010715122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty