Provider Demographics
NPI:1922605237
Name:TILLES, SHAYNA ARIEL (RDH, CDA, EFDA)
Entity Type:Individual
Prefix:
First Name:SHAYNA
Middle Name:ARIEL
Last Name:TILLES
Suffix:
Gender:F
Credentials:RDH, CDA, EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 KENSINGTON POND CT
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-5579
Mailing Address - Country:US
Mailing Address - Phone:770-634-9664
Mailing Address - Fax:
Practice Address - Street 1:1875 OLD ALABAMA RD STE 130
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2262
Practice Address - Country:US
Practice Address - Phone:770-998-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH044019124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist