Provider Demographics
NPI:1881214864
Name:MOSLEY, SHANTE' L (RDH, BSDH)
Entity Type:Individual
Prefix:
First Name:SHANTE'
Middle Name:L
Last Name:MOSLEY
Suffix:
Gender:F
Credentials:RDH, BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 BELHAVEN LN SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-6802
Mailing Address - Country:US
Mailing Address - Phone:404-698-6629
Mailing Address - Fax:
Practice Address - Street 1:2118 BELHAVEN LN SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-6802
Practice Address - Country:US
Practice Address - Phone:404-698-6629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH012610124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist