Provider Demographics
NPI:1790800415
Name:STOCKWELL, KARYN LYNN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KARYN
Middle Name:LYNN
Last Name:STOCKWELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 FREY RD NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5409
Mailing Address - Country:US
Mailing Address - Phone:770-424-9292
Mailing Address - Fax:770-424-5093
Practice Address - Street 1:3900 FREY RD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5409
Practice Address - Country:US
Practice Address - Phone:770-424-9292
Practice Address - Fax:770-424-5093
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA96621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice